405 IAC 1-1-1 - Definitions
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 4-6-10; IC 12-13-7-3; IC 12-15; IC 16-19; IC 16-21; IC 16-28; IC 16-29-4-2
Sec. 1.
The following definitions in this section apply throughout this article:
(1) "Attending
physician" means a physician who is responsible for developing and maintaining
the plan of care for a Medicaid patient.
(2) "CMS" means the Centers for Medicare and
Medicaid Services, a federal agency within the United States Department of
Health and Human Services.
(3)
"CRF/DD" or "CRFs/DD" means a community residential facility or facilities for
the developmentally disabled.
(4)
"CRMNF" means a comprehensive rehabilitative management needs facility as
defined in
460 IAC 9-1-2.
(5) "ICF/IID" or "ICFs/IID" means an
institution or institutions for individuals with intellectual disabilities, as
described in IC 16-29-4-2, or a medical institution or that portion thereof
providing such care, which is qualified as such an institution pursuant to the
provisions of Title XIX of the Social Security Act.
(6) "IMFCU" means the Medicaid fraud control
unit established by the Indiana attorney general under the authority of IC
4-6-10.
(7) "ISDH" means the state
department of health as defined in IC 16-19.
(8) "Medicaid" means that program described
by IC 12-15 and this title, in which the office administers benefits and makes
payments to providers for covered services provided to members.
(9) "Member" means an individual who has been
determined by the office to be eligible for payment of covered services
pursuant to IC 12-15.
(10) "Nursing
facility" means a comprehensive care facility licensed under IC 16-28, or a
hospital based long term care facility licensed under IC 16-21 and enrolled as
a Medicaid provider.
(11) "Nursing
facility services" has the meaning set forth in
405 IAC 5-31-1.1.
(12) "Office" means the Indiana family and
social services administration and its offices, divisions, or
designees.
(13) "Parameter" means
the maximum amount or duration, or both, of a service within appropriate limits
for which payment may be made without prior authorization or exception due to
medical necessity or contraindications.
(14) "Prior authorization" has the meaning
set forth in
405 IAC 5-2-20.
(15) "Provider" means an individual, state
agency, local agency, corporate entity, or business entity that has been
enrolled in Medicaid pursuant to
405 IAC 1-1.4-3.
(16) "Provider manual" means the interpretive
document or documents issued by the office to providers to inform them of their
obligations under Medicaid to which they must conform to retain their provider
status and receive payment for appropriate services, and to provide them
essential information for understanding Medicaid as it relates to the services
for which they are qualified to provide under the state statutes.
(17) "Third party" means an insurer,
individual, institution, corporation, or public or private agency who is or may
be liable to pay all or part of the medical costs of injury, disease, or
disability of an applicant or recipient of Medicaid. (18) "Usual and customary
charge" means the amount a provider offers to charge the general public for a
service or supply, including applicable offered discounts. General public does
not include individuals who are enrolled in or a member of an insurance plan
that covers the services or supplies in question, or receive a discount of the
services or supplies through a program with selective criteria that disqualify
certain individuals from eligibility in the program.
Notes
Transferred from the Division of Family and Children
(470 IAC 5-1-1) to the Office of
the Secretary of Family and Social Services (405 IAC 1-1-1) by P.L. 9-1991,
SECTION
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