Section He-W 530.01 - Definitions(a) "Co-payment" means an amount to be paid by the recipient to an enrolled New Hampshire medicaid provider.(b) "Department" means the New Hampshire department of health and human services.(c) "Generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, or the recommendations of physician specialists practicing in relevant clinical areas or of various physician specialty societies.(d) "Medicaid" means the Title XIX and Title XXI programs administered by the department, which makes medical assistance available to eligible individuals.(e) "Medically necessary" means health care services that a licensed health care provider, exercising prudent clinical judgment, would provide, in accordance with generally accepted standards of medical practice, to a recipient for the purpose of evaluating, diagnosing, preventing, or treating an acute or chronic illness, injury, disease, or its symptoms, and that are: (1) Clinically appropriate in terms of type, frequency of use, extent, site, and duration, and consistent with the established diagnosis or treatment of the recipient's illness, injury, disease, or its symptoms;(2) Not primarily for the convenience of the recipient or the recipient's family, caregiver, or health care provider;(3) No more costly than other items or services which would produce equivalent diagnostic, therapeutic, or treatment results as related to the recipient's illness, injury, disease, or its symptoms; and(4) Not experimental, investigative, cosmetic, or duplicative in nature.(f) "Multi-source pharmaceutical product" means a product which is available from more than one manufacturer.(g) "Non-preferred prescription drug" means a medication that has been determined to have an alternative drug available that is clinically equivalent and has been clinically reviewed and approved by the NH Pharmacy and Therapeutics Committee or the NH Drug Use Review Board established in He-C 5010 and has been included in the department's preferred drug list as non-preferred.(h) "Preferred prescription drug" means a medication that has been clinically reviewed and approved by the NH Pharmacy and Therapeutics Committee or the NH Drug Use Review Board established in He-C 5010 and has been included in the department's preferred drug list based on its proven clinical and cost effectiveness.(i) "Preferred Drug List (PDL) " means a formal published list of specific prescription drug products by brand and generic name divided into 2 separate categories as either preferred or non-preferred.(j) "Provider" means an entity or individual who furnishes health care services or supplies to medicaid recipients under an agreement with the department, and is licensed or certified pursuant to applicable state law to provide such services and supplies.(k) "Recipient" means any individual who is eligible for and receiving medical assistance under the medicaid program.(l) "Service" means medical care or a medical product for which payment is made by New Hampshire medicaid.(m) "Service limit" means a finite number of visits or units of service per recipient per specified time period for which payment is made by New Hampshire medicaid.(n) "Single source pharmaceutical product" means a brand name product which is available from only one manufacturer.(o) "State fiscal year" means July 1 through June 30.(p) "Third party entity" means the agency under contract with the department to collect and process premium payments for medicaid recipients.(q) "Title XIX" means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.(r) "Title XXI" means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.(s) "Unit" means a determinate quantity for which a particular service is rendered.(t) "Visit" means all services provided to a recipient per appointment or encounter with a provider.N.H. Admin. Code § He-W 530.01
(See Revision Note at chapter heading He-W 500); ss by #5914, eff 11-1-94; ss by #6745, eff 5-1-98, EXPIRED: 12-31-98; ss by #6925, eff 1-1-99; ss by #8780, INTERIM, eff 1-1-07, EXPIRES: 6-30-07; ss by #8929, eff 6-30-07; amd by #8983, INTERIM, eff 9-21-07, EXPIRES: 3-19-08; ss by #9103, eff 3-12-08; amd by #10139, eff 7-1-12
Amended by Volume XXXVI Number 23, Filed June 9, 2016, Proposed by #11101, Effective 5/25/2016, Expires 5/25/2026.