048-6 Wyo. Code R. §§ 6-4 - Definitions

(a) "ACIP". The Advisory Committee for Immunization Practices of the Centers for Disease Control, United States Public Health Service, HHS.

(b) "Administrative transportation". Transportation by means other than an ambulance to obtain covered services.

(c) "Ambulance". An ambulance as defined by Chapter 15, which definition is incorporated by this reference.

(d) "Appropriate immunizations". Those immunizations recommended by the Division of Preventive Medicine, and the ACIP recommended schedule of vaccinations.

(e) "Appropriate laboratory tests". Those tests which a HEALTH CHECK provider determines to be appropriate for a recipient under age twenty-one. Appropriate laboratory tests may include a blood lead level test, anemia tests, sickle cell test, and tuberculin test.

(f) "Chapter 3". Chapter 3, Provider Participation, of the Wyoming Medicaid Rules.

(g) "Chapter 15". Chapter 15, Ambulance Services, of the Wyoming Medicaid rules.

(h) "Chapter 26". Chapter 26, Covered Services, of the Wyoming Medicaid rules.

(i) "Claim". A request by a HEALTH CHECK provider for payment of Medicaid funds for services provided to a recipient.

(j) "Covered service". Services provided to a recipient that may be reimbursed as provided in this Chapter.

(k) "Dental screening". An oral assessment of a recipient by a HEALTH CHECK provider.

(l) "Department". The Wyoming Department of Health, its designee, agent or successor.

(m) "Department of Family Services (DFS)". The Wyoming Department of Family Services, its designee, agent or successor.

(n) "Developmental screening". An examination of a recipient and an evaluation of a recipients activities to determine whether he or she is within the normal range of achievement for the recipients age group and cultural background.

(o) "Division". The Division of Health Care Financing of the Department, its successor, agent or designee.

(p) "Division of Preventive Medicine". The Division of Preventive Medicine of the Department, its successor, agent or designee.

(q) "Early and periodic screening, diagnosis and treatment services ("EPSDT)". Early and periodic screening, diagnosis and treatment services as defined in 42 U.S.C. § 1396 d(r), which is incorporated by this reference.

(r) "Excess payments". Medicaid funds received by a HEALTH CHECK provider which exceed the Medicaid allowable payment.

(s) "Expanded services". Medically necessary health care, including diagnostic services and treatment, which are reimbursable pursuant to 42 U.S.C. § 1396 d, and which are not otherwise reimbursable under the Wyoming Medicaid State Plan.

(t) "Eyecare practitioner". An optometrist or an ophthalmologist.

(u) "HEALTH CHECK". A comprehensive EPSDT screening examination of a well-child or young adult up to age twenty-one which includes all of the following:

(i) A comprehensive health and developmental history, including a developmental screening, a nutritional screening, and a mental health screening;

(ii) An unclothed physical examination;

(iii) Appropriate immunizations;

(iv) Appropriate laboratory tests;

(v) Age appropriate health education and counseling;

(vi) Vision screening;

(vii) Hearing screening;

(viii) Dental screening; and

(ix) Treatment or referral services for any diagnosed abnormalities.

(v) "HEALTH CHECK periodicity schedule". The periodicity schedule established pursuant to Section 9.

(w) "HEALTH CHECK program". The Wyoming EPSDT program.

(x) "HEALTH CHECK provider". A provider that meets the requirements of Section 5.

(y) "Health education and counseling". Education of and counseling to recipients and their parents or guardians to assist them in understanding the benefits of healthy lifestyle practices; accident and disease prevention; the services available under the HEALTH CHECK program and where and how to obtain them; and that medically necessary HEALTH CHECK services are available without cost to recipients under age twenty-one.

(z) "Hearing screening". Age-appropriate hearing screening.

(aa) "Lead screening verbal assessment". An evaluation of a recipient's exposure to dangerous levels of lead using the guidelines set forth by the Department from time to time in Manuals or HEALTH CHECK provider bulletins.

(bb) "HHS". The United States Department of Health and Human Services, its agent, designee or successor.

(cc) "Medicaid". Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services Act.

(dd) "Medicaid allowable payment". The maximum Medicaid reimbursement for covered services as specified by this Chapter.

(ee) "Medicaid fee schedule". The Medicaid fee schedule established pursuant to Chapter 3, which is incorporated by this reference.

(ff) "Medically necessary". A health service that is required to diagnose, treat, cure or prevent an illness, injury or disease which has been diagnosed or is reasonably suspected, to relieve pain or to improve and preserve health and be essential to life. The services must be:

(i) Consistent with the diagnosis and treatment of the recipient's condition;

(ii) Recognized as the prevailing standard or current practice among the provider's peer group;

(iii) Required to meet the medical needs of the recipient and undertaken for reasons other than the convenience of the recipient and the provider; and

(iv) Provided in the most efficient manner and/or setting consistent with appropriate care required by the recipients condition.

(gg) "Medicare". The health insurance program for the aged and disabled under Title XVIII of the Social Security Act.

(hh) "Mental health screening". A consideration by a HEALTH CHECK provider of a recipients social interaction, behavior, thinking patterns, feelings and physical problems.

(ii) "Non-medical services". Services, supplies, items or equipment that are not medical in nature, as determined by the Division, even if medically necessary. Non-medical services includes, but is not limited to, communication assisted technology boards.

(jj) "Nurse midwife". A registered nurse who is certified as a nurse midwife by the American College of Nurse-midwives.

(kk) "Nurse practitioner". An "advanced practitioner of nursing" as defined by W.S. § 33-21-120(a)(i), which is incorporated by this reference, or a registered nurse that is certified or licensed as a nurse practitioner pursuant to the laws of another state.

(ll) "Nutritional screening". A consideration by a HEALTH CHECK provider of a recipients nutritional status, eating habits, use of alcohol/drugs and tobacco.

(mm) "OBRA' 89". The Omnibus Budget Reconciliation Act of 1989, Pub. L. No. 101-239.

(nn) "Ophthalmologist". A physician who has successfully completed a postgraduate ophthalmology program of at least three years duration that is accredited by the American Board of Ophthalmology.

(oo) "Optometrist". A person licensed to practice optometry by the Wyoming State Board of Examiners of Optometry or a similar agency in another state.

(pp) "Physician". A person licensed to practice medicine or osteopathy by the Wyoming State Board of Medical Examiners or a comparable agency in another state.

(qq) "Prior authorized". Prior authorized pursuant to the procedures of Chapter 3, which are incorporated by this reference.

(rr) "Provider". A provider as defined by Chapter 3, which definition is incorporated by this reference.

(ss) "Public health nurses". A registered nurse who is either under contract to the county to perform public health nursing functions or is an employee of the Department that is assigned public health nursing functions.

(tt) "Recipient" or "recipient under age twenty-one". An individual under age twenty-one that has been determined eligible for Medicaid. A recipient is under age twenty-one before or during the month in which he or she turns twenty-one years of age.

(uu) "Screening". An evaluation of a recipient under age twenty-one by a HEALTH CHECK provider to determine the need for a full assessment by a qualified specialist. A screening includes a direct referral to an appropriate specialist when medically necessary.

(vv) "Services". Health services, medical supplies or equipment.

(ww) "Treatment and referral services". Medically necessary services that are reimbursable pursuant to the Wyoming State Medicaid Plan that are furnished to a recipient under age twenty-one by a provider after a referral from a HEALTH CHECK provider.

(xx) "Unclothed physical examination". A physical examination pursuant to the guidelines set forth by the Department in Manuals or HEALTH CHECK provider bulletins.

(yy) "Usual and customary charge". The provider's charge to the general public for the same or similar services.

(zz) "Vision screening". Administration by a HEALTH CHECK provider of age-appropriate vision screening which includes the following:

(i) General external examination and evaluation of ocular motility;

(ii) Visual acuity examination;

(iii) Pupillary light reflex test; and

(iv) Intraocular examination with an ophthalmoscope.

Notes

048-6 Wyo. Code R. §§ 6-4