Connecticut Administrative Code › Title 17 - Public Assistance and Welfare Services › 134d - Medical Assistance › Title XIX Rates for Community Health Centers › Section 17-134d-86 - Medicaid payment for general hospital outpatient emergency and non-emergency visits to a hospital emergency room and outpatient clinic visits

Current through July 10, 2024
(a)
Definitions
(1) "Department" means The State of
				Connecticut Department of Income Maintenance or its agent.
(2) "Emergency room" means that part of a
				general hospital that is designed, organized, equipped, and staffed to provide
				initial diagnosis and treatment of patients requiring immediate physician,
				dental, or allied services.
(3)
				"Emergency visit" means an urgent encounter requiring the immediate
				decision-making and medically necessary action to prevent death or any further
				disability for patients in health crises (including labor and delivery). Such
				medical conditions are manifested by acute symptoms of sufficient severity
				(including severe pain) such that the absence of immediate medical attention
				could reasonably be expected to result in placing the patient's health in
				serious jeopardy, serious impairment to bodily functions, or serious
				dysfunction of any bodily organ or part. In order to be considered urgent, the
				encounter must occur within seventy-two (72) hours from the onset of the
				presenting medical condition.
(4)
				"General hospital" means a short-term hospital having facilities, medical staff
				and all necessary personnel to provide diagnosis, care and treatment of a wide
				range of acute conditions, including injuries, and shall include a children's
				general hospital which means a short-term hospital having facilities, medical
				staff and all necessary personnel to provide diagnosis, care and treatment of a
				wide range of acute conditions among children, including injuries.
(5) "Medically necessary" means medical care
				provided to:
(A) Correct or diminish the
				adverse effects of a medical condition;
(B) Assist an individual in attaining or
				maintaining an optimal level of well being;
(C) Diagnose a condition; or
(D) Prevent a medical condition from
				occurring.
(6)
				"Non-emergency visit" means a medically necessary non-urgent encounter
				presenting a medical condition which does not meet the requirements for an
				emergency visit as defined in this section but, rather, requires a routine
				level of ambulatory health care. Such conditions may be characterized by the
				fact that they may also be treated in an alternate health care setting, such
				as: community-based physician's office, walk-in clinic, comprehensive health
				center, neighborhood health center and other free-standing primary health care
				clinics because such medical conditions do not require the skills, resources
				and equipment of a hospital emergency room. Such visits may include primary
				health care or the initial diagnosis and treatment of routine acute or chronic
				illnesses whether on a scheduled or unscheduled basis.
(7) "Outpatient" means a patient of an
				organized medical facility, or distinct part of that facility who is expected
				by the facility to receive and who does not receive professional services for
				less than a 24-hour period regardless of the hour of admission, whether or not
				a bed is used, or whether or not the patient remains in the facility past
				midnight.
(8) "Outpatient clinic
				visit rate" means the rate set by the Department using the methodology as
				required by subsection 17-312(d) of the General Statutes of the State of
				Connecticut.