Section He-W 566.01 - Definitions(a) "By report" means a written description of the service provided and the medical necessity of same as required by the department to be submitted with certain claims for payment of such claims.(b) "Comprehensive orthodontic treatment" means diagnosis, long-term treatment, periodic evaluations, and retention, leading to improvement of a recipient's malocclusion.(c) "Deciduous teeth", also known as primary teeth, means the 20 teeth that erupt first and are normally shed and replaced by secondary teeth.(d) "Department" means the New Hampshire department of health and human services.(e) "Destruction of tissue" means demonstrable, traumatic alteration of soft or hard tissue architecture with history of treatment of pain.(f) "Diagnostic model" means a model or representation that demonstrates all erupted teeth, the gingival tissue surrounding the anterior and posterior arches, and the true occlusal relationships of the teeth and tissues.(g) "Differential diagnosis" means a condition or disorder consistent with and reasonably thought to be the cause of the history, signs, and symptoms presented by the recipient which is determined by a process that differentiates it from other conditions or disorders with similar signs or symptoms.(h) "Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services" means a program, pursuant to 42 CFR 440.40, designed to provide preventative health care, diagnostic services, and early detection and treatment of disease or abnormalities to Title XIX eligible individuals under age 21.(i) "Interceptive orthodontic treatment" means an intervention in the initial stages of a developing problem related to the dentition, to lessen severity of the malformation and to eliminate its cause.(j) "Limited orthodontic treatment" means orthodontic treatment not involving the entire dentition.(k) "Malocclusion" means improper alignment of the biting or chewing surfaces of upper and lower teeth that results from a deviation of the alignment of the teeth from the ideal alignment.(l) "Medicaid" means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.(m) "Medically necessary" means: (1) For individuals under age 21, reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent the worsening of conditions that endanger life, cause pain, result in illness or infirmity, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction, and no other equally effective course of treatment is available or suitable for the EPSDT recipient requesting a medically necessary service; and(2) For individuals age 21 and over, 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: a. 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;b. Not primarily for the convenience of the recipient or the recipient's family, caregiver, or health care provider;c. 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; andd. Not experimental, investigative, cosmetic, or duplicative in nature.(n) "Palliative treatment" means minor treatment to reduce the pain of a disease, illness, or injury of the tooth or teeth excluding non-treatment activities such as writing a prescription, dispensing a drug or medication, or telephone consultation with or about a recipient.(o) "Radiograph" means an image or picture produced by exposure to ionizing radiation of a radiation-sensitive film, phosphorous plate, emulsion, or digital sensor.(p) "Recipient" means any individual who is eligible for and receiving medical assistance under the medicaid program.(q) "Severe handicapping malocclusion" means a malocclusion resulting from severe skeletal discrepancies that can be objectively documented as causing the following: (2) Significantly impaired speech, mastication, breathing or swallowing; or(3) Severe psychological trauma or severe antisocial behavior.(r) "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.(s) "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.N.H. Admin. Code § He-W 566.01
(See Revision Note at chapter heading He-W 500); ss by #5639, eff 6-17-93; ss by #7012, eff 6-15-99; ss by #7912, eff 7-1-03; ss by #9902, eff 6-1-11; amd by #10139, eff 7-1-12
Amended by Volume XXXIX Number 24, Filed June 13, 2019, Proposed by #12782, Effective 5/21/2019, Expires 11/18/2019.Amended by Volume XL Number 2, Filed January 9, 2020, Proposed by #12937, Effective 12/7/2019, Expires 12/7/2029.