S.D. Admin. R. 44:06:01:00

Current through Register Vol. 51, page 67, December 16, 2024

Section 44:06:01:00 - Definitions

Terms used in this chapter mean:

(1) "Care coordination services," services to promote the effective and efficient organization and utilization of resources to ensure access to necessary comprehensive services for children with chronic medical conditions and their families;

(2) "Chronic medical condition," condition has existed or is expected to exist for two years or more, requires evaluation, consultation and medical treatment, and is a coverable condition under the CSHS program as listed in § 44:06:06:01;

(3) "Client," an individual who is determined by CSHS to be eligible for and receiving services;

(4) "Consultation," the medical examination and testing by a specialist needed to determine the cause of and possible treatment for a suspected or known chronic medical condition;

(5) "Copay," the obligation of the family or legal guardian for either partial or full payment of the medical cost after submission of the bill to a health insurance plan;

(6) "Cost share," a family's percentage of financial participation in the cost of CSHS authorized services determined by family size and income;

(7) "CSHS," children's special health services;

(8) "Deductible," the specified amount that must be met in medical costs and paid by the family or policy holder before a health insurance plan will pay;

(9) "Department," the South Dakota Department of Health;

(10) "Diagnostic services," use of scientific medical methods to establish the cause and nature of a person's illness or chronic medical condition;

(11) "Financial assistance," determined amount paid to a provider by CSHS on a client's behalf;

(12) "Individual case review," the process whereby a team of individuals from the department reviews a request to consider an individual's medical eligibility or treatment;

(13) "Participating provider," a provider who has a current, signed participating provider agreement with CSHS;

(14) "Primary care physician," the physician to whom a family or individual goes for management of care for acute illness and ongoing health needs;

(15) "Secretary," the South Dakota secretary of health or the secretary's designee;

(16) "Third-party resource," a public or private agency or entity which is or may be liable to pay all or part of the medical costs of an applicant or client, including private insurance, Civilian Health and Medical Program Uniformed Services, Medicaid, Medicare, Indian Health Services, and other sources of funds available to the applicant or client for medical care;

(17) "Treatment," medical or surgical intervention, or both, to alleviate a chronic medical condition; and

(18) "Usual and customary charge," the individual provider's normal charge to the general public for a specific service on the date the service was provided.

S.D. Admin. R. 44:06:01:00

20 SDR 91, effective 12/19/1993; 23 SDR 91, effective 12/9/1996; 30 SDR 198, effective 6/23/2004; 33 SDR 106, effective 12/26/2006.

General Authority: SDCL 34-1-21.

Law Implemented: SDCL 34-1-21.