Ga. Comp. R. & Regs. R. 350-1-.01 - Definitions
(1) "Act" means the Georgia Medical Assistance Act of 1977;
O.C.G.A. Title 49, Article 7.
(2) "Administrative Review" means the formal reconsideration,
as a result of the proper and timely submission of a provider's request
therefor, by any Departmental Division, Office, or Unit which has proposed an
adverse action which will aggrieve a party if it is carried out.
(3) "Adverse Action" means an instance in which the
Department:
(a) denies or reduces the amount of reimbursement claimed by a
provider;
(b) recovers funds previously paid to a provider, other than
through lawsuit;
(c) sets or changes a provider's reimbursement rate;
(d) withholds reimbursement from a provider;
(e) denies payment for future admissions to a nursing facility,
except as provided in Chapter 350-3 of these Rules;
(f) suspends, terminates, or refuses to enroll, re-enroll, or
reinstate a provider or prospective provider; or
(g) performs any other act which aggrieves a provider.
(4) "Aggrieved" means to have received notice of a loss or
injury in fact to an interest within the zone of interests protected by a law
or regulation governing Medical Assistance.
(5) "Applicant for medical assistance" means a person who has
made application for certification as being eligible, generally, to have
medical assistance paid in his/her behalf pursuant to the terms of the State
Plan and whose application has not been acted upon favorably.
(6) "Board" means the Board of Medical Assistance.
(7) "Business day" means day on which the Department is
officially open to conduct its affairs.
(8) "Commissioner" means the Commissioner of Medical
Assistance.
(9) "Department" means the Department of Medical
Assistance.
(10) "Hearing" means a formal proceeding before an
Administrative Law Judge in which parties affected by an action or an intended
action of the Department shall be allowed to present testimony, documentary
evidence, and argument as to why such action should or should not be
taken.
(11) "Administrative Law Judge (ALJ)" means a member of the
State Bar of Georgia authorized by the Commissioner to administer the hearing
provisions of the medical assistance program as set out in O.C.G.A. §
49-4-153.
(12) "Medical Assistance" means payment to a provider of a part
of or all of the cost of certain items of medical or remedial care or services
rendered by a provider to a recipient of medical assistance, provided such
items are rendered and received in accordance with such provisions of Title XIX
of the federal Social Security Act of 1935, as amended, regulations promulgated
pursuant thereto by the Secretary of Health and Human Services, all applicable
laws of the State of Georgia, the State Plan, and regulations of the Department
which are in effect on the date on which the care or services are
rendered.
(13) "Notice of hearing" means
(a) for the purpose of rule-making, a written statement of the
substance of a proposed rule which will afford notice to all interested
persons, such notice being given by mail or by publication at least thirty (30)
days prior to the date of hearing; provided, however, that when the Board finds
it necessary under Rule 350-2-.04, such notice may be shortened or eliminated;
and
(b) for the purpose of contested cases, a written statement
issued pursuant to Chapter 350-4 of these Rules by an Administrative Law Judge
appointed to preside over a hearing.
(14) "Party" means any person against whom the Department has
taken an adverse action and who has been approved to participate in a hearing
by the Department or by the presiding Administrative Law Judge.
(15) "Person" means any individual, partnership, corporation,
or other entity recognized under Georgia law.
(16) "Pleadings" consist of the notice of adverse action issued
by the Department which aggrieves the provider, the provider's Request for
hearing requesting review of the adverse action, and any amendments to such
documents.
(17) "Program" means all of the functions of the Georgia
Department of Medical Assistance.
(18) "Provider of medical assistance" means a person or
institution, public or private, which possesses all licenses, permits,
certificates, approvals, registrations, charters, and other forms of permission
issued by entities other than the Department, which forms of permission are
required by law either to render care or to receive medical assistance in which
federal financial participation is available, which meets the further
requirements for participation prescribed by the Department, and which is
enrolled, in the manner and according to the terms prescribed by the
Department, to participate in the State Plan.
(19) "Reasonable time" means such time as is appropriate to do
what is required to be done, as soon as circumstances will permit; any time
which is not manifestly unreasonable may be fixed by agreement of the parties,
and what is reasonable depends on the nature, purpose, and circumstances of
each case.
(20) "Recipient of medical assistance" means a person who has
been certified eligible, pursuant to the terms of the State Plan, to have
medical assistance paid in his/her behalf.
(21) "Request for Hearing" is a written document submitted to
the Department seeking formal redress of an action by the Department which
aggrieves the person making the request. To be effective, a request for Hearing
must comply with the provisions of Rule 350-4-.05.
(22) "Rule" means each Department regulation or written
statement of general or particular applicability which implements law governing
the Department's organization or its administration of the State Plan pursuant
to the authority granted under O.C.G.A., §
49-4-142, et seq., as amended;
provided, however, that the amount, duration, scope, and terms and conditions
of eligibility for and receipt of medical assistance, statements of general or
specific policy and interpretations thereof, informational notices, contracts,
and policy and procedure manuals and amendments thereto, are specifically
excluded.
(23) "State Plan" means all documentation submitted by the
Commissioner, on behalf of the Department, to and for approval by the Secretary
of Health and Human Services pursuant to Title XIX of the federal Social
Security Act of 1935, as amended.
(24) Time Computed. The computation of any period of time
referred to in these Rules shall begin with the first day following that on
which the act initiating such period of time occurs. When the last day of the
period so computed is a day on which the Department is closed, the period shall
run until the end of the next business day.
(25) All petitions, requests, notices, and decisions referred
to in these Rules must be in writing.
Notes
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