Utah Admin. Code R414-1-2 - Definitions
The following definitions are used throughout the rules of
the
(1) "Act " means the
federal Social Security Act .
(2)
"Applicant " means any person who requests assistance under the medical programs
available through the Division .
(3)
"Categorically needy " means an aged, blind or disabled individual or family or
child:
(a) who is otherwise eligible for
Medicaid; and
(i) who meets the financial
eligibility requirements for Aid to Families with Dependent Children as in
effect in the Utah Medicaid State Plan on July 16, 1996; or
(ii) who meets the financial eligibility
requirements for Supplemental Security Income (SSI) or an optional State
supplement, or is considered under Section 1619(b) of the federal Social
Security Act to be an SSI recipient ; or
(iii) who is a pregnant woman whose household
income does not exceed 133% of the federal poverty guideline; or
(iv) is under age six and whose household
income does not exceed 133% of the federal poverty guideline; or
(v) who is a child under age one born to a
woman who was receiving Medicaid on the date of the child's birth and the child
remains with the mother; or
(vi)
who is at least six years of age, but not yet 18 years of age , or is at least
six years of age , but not yet 19 years of age and was born after September 30,
1983, and whose household income does not exceed 100% of the federal poverty
guideline; or
(vii) who is aged or
disabled and whose household income does not exceed 100% of the federal poverty
guideline; or
(viii) who is a child for whom an adoption
assistance agreement with the state is in effect.
(b) whose categorical eligibility is
protected by statute.
(4) "Code of Federal
Regulations " (CFR) means the publication by the Office of the Federal Register,
specifically Title 42, used to govern the administration of the Medicaid
Program .
(5) "Member " means a
person the Division or its constituted agent has determined to be eligible for
assistance under the Medicaid program .
(6) "CMS " means The Centers for Medicare and
Medicaid Services, a federal agency within the United States (U.S.) Department
of Health and Human Services. Programs for which CMS is responsible include
Medicare, Medicaid, and the Children's Health Insurance Program.
(7) "Department " means the Department of
Health and Human Services (DHHS).
(8) "Director " means the director of the
Division .
(9) "Division " means the
Division of Integrated Healthcare within the Department .
(10) "Emergency medical condition " means a
medical condition showing acute symptoms of sufficient severity that the
absence of immediate medical attention could reasonably be expected to result
in:
(a) placing the patient's health in
serious jeopardy;
(b) serious
impairment to bodily functions;
(c)
serious dysfunction of any bodily organ or part; or
(d) death.
(11) "Emergency service " means immediate
medical attention and service performed to treat an emergency medical
condition . Immediate medical attention is treatment given within 24 hours of
the onset of symptoms or within 24 hours of diagnosis.
(12) "Emergency Services Only Program " means
a health program designed to cover a specific range of emergency
services.
(13) "Executive Director "
means the executive director of the Department .
(14) "InterQual " means the McKesson Criteria
for Inpatient Reviews, a comprehensive, clinically based, patient focused
medical review criteria and system developed by McKesson Corporation.
(15) "Medicaid agency" means DHHS.
(16) "Medical assistance program " or
"Medicaid program " means the state program for medical assistance for persons
who are eligible under the state plan adopted pursuant to Title XIX of the
federal Social Security Act ; as implemented by Title 26, Chapter 18, Medical
Assistance Act .
(17) "Medical or
hospital assistance " means the service furnished or a payment made to or on
behalf of a recipient under medical programs available through the
Division .
(18) "Medically necessary
service " means that:
(a) it is reasonably
calculated to prevent, diagnose, or cure conditions in the recipient that
endanger life, cause suffering or pain, cause physical deformity or
malfunction, or threaten to cause a handicap; and
(b) there is no other equally effective
course of treatment available or suitable for the recipient requesting the
service that is more conservative or substantially less costly.
(19) "Medically needy " means an
aged, blind, or disabled individual or family or child who is otherwise
eligible for Medicaid, who is not categorically needy , and whose income and
resources are within limits set under the Medicaid State Plan.
(20) "Medical standards ," as applied in this
rule, means that an individual may receive reasonable and necessary medical
services up until the time a physician makes an official determination of
death.
(21) "Prior authorization "
means the required approval for provision of a service that the provider must
obtain from the Department before providing the service. Details for obtaining
prior authorization are found in Section I of the Utah Medicaid Provider
Manual.
(22) "Provider " means any
person, individual or corporation, institution or organization that provides
medical, behavioral or dental care services under the Medicaid program and who
has entered into a written contract with the Medicaid program .
(23) "Recipient " means a person who has
received medical or hospital assistance under the Medicaid program , or has had
a premium paid to a managed care entity.
(24) "Undocumented alien " means an alien who
is not recognized by Immigration and Naturalization Services as being lawfully
present in the United States.
(25)
"Utilization review " means the Department provides for review and evaluation of
the utilization of inpatient Medicaid services provided in acute care general
hospitals to patients entitled to benefits under the Medicaid plan.
(26) "Utilization Control " means the
Department implements a statewide program of surveillance and utilization
control that safeguards against unnecessary or inappropriate use of Medicaid
services, safeguards against excess payments, and assesses the quality of
services available under the plan. The program meets the requirements of 42
CFR, Part 456.
Notes
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No prior version found.