Section He-W 521.01 - Definitions(a) "Applicant" means a person on whose behalf application is being made for any of the department of health and human service's program.(b) "Co-insurance" means the percentage of the other insurance or Medicare allowed charge that is not paid by the other insurance or Medicare, but is the responsibility of the recipient.(c) "Co-pay" means a fixed payment for a covered service, paid when an individual receives services.(d) "Deductible" means a set dollar amount that is the out-of-pocket expense an individual is responsible to pay, within a specific time frame, before insurance pays a claim.(e) "Department" means the New Hampshire department of health and human services.(f) "Formal provider bulletin" means official medicaid notices sent to the providers and maintained on the medicaid management information system website.(g) "Managed care organization (MCO)" means an entity that has a comprehensive risk-based contract with the department to provide managed medicaid health care services.(h) "Medicaid" means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.(i) "Medicaid allowable" means the maximum amount medicaid shall pay for a service. Medicaid allowables are in the medicaid fee schedules on the medicaid management information system website.(j) "Medicaid management information system (MMIS)" means the fee for the service system for mechanized claims processing and information retrieval recommended by the Centers for Medicare and Medicaid Services (CMS) for the implementation of the requirements of state fiscal administration pursuant to 42 CFR 433, Subpart C.(k) "Medicare" means the health insurance program under Title XVIII of the Social Security Act for people who are age 65 or older, disabled, or both, regardless of income, obtained through the U.S. Department of Health and Human Services, Social Security Administration.(l) "Provider" means "provider" as defined in RSA 167:58, V, namely "any individual, partnership, corporation or entity furnishing services under a written contract with the department."(m) "Recipient" means any individual who received or receives medical assistance under the medicaid program.(n) "Recoupment" means medicaid recovers funds paid in error by reducing future payments until the recovery is complete.(o) "Responsible party" means a person or organization who is wholly, or in part, responsible for paying for the medical services of an individual. Individual responsible parties are usually relatives such as a parent or spouse. Organization responsible parties are usually insurance carriers or Medicare.(p) "Third party" means the process as described in RSA 167:4-b whereby any private insurer, health maintenance organization, hospital service organization, medical service or health services corporation, governmental agency, or any individual, organization, entity, or agency is authorized or under legal obligation to pay for medical services for an eligible recipient.(q) "Third party liability" means the obligation of any private insurance, Medicare, individual, institution, corporation, or agency that is liable to pay all or part of the medical cost of illness, injury, disease, or disability of a recipient.(r) "Third party payor" means the third party that pays or insures health or medical expenses on behalf of a recipient or recipients.(s) "Self-audit" means an examination, review, or other inspection performed both by and within a given health care professional's practice or business. It can be initiated by the entity or by an external entity.N.H. Admin. Code § He-W 521.01
Derived from Number 10, Filed March 7, 2024, Proposed by #13884, Effective 2/22/2024, Expires 2/22/2034 (See Revision Note at chapter heading for He-W 500) (See also part heading for He-W 521).