Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Services Provided by Psychiatric Residential Treatment Facilities Providers › Section 17b-262-805 - Definitions

Current through July 10, 2024
As used in section 17b-262-804 to section 17b-262-816, inclusive, of the Regulations of Connecticut State Agencies:
(1) "Active treatment" means "active treatment" as defined in 42 CFR, Part 441, section 44l.l54;
(2) "Acute" means having rapid onset, severe symptoms and a short course;
(3) "Allied Health Professional" or "AHP" means a licensed individual who is qualified by special training, education, skills and experience in behavioral health care and treatment and shall include, but shall not be limited to: psychologists, social workers, psychiatric nurses, professional counselors and other qualified therapists as defined in Title 20 of the Connecticut General Statutes;
(4) "Authorization" means the approval of payment for services or goods by the department based on a determination of medical necessity and appropriateness. For elective admissions, authorization also serves as the certification of need as defined in this section;
(5) "CMS" means the Centers for Medicare and Medicaid Services;
(6) "Certification of need" means an evaluation process for clients who are under consideration for admission to a PRTF;
(7) "Client" means a person eligible for goods or services under Medicaid who is under age twenty-one at the time services are received. If a client received services immediately before reaching age twenty-one, payment shall be available for services received before the earlier of the date that the client no longer requires the services or the date that the client reaches age twenty-two;
(8) "Department" means the Department of Social Services or its agent;
(9) "Elective admission" means any admission to a PRTF that is non-emergent, including, but not limited to, transfers from one PRTF to another;
(10) "Independent team" means a team that meets the requirements set forth in 42 CFR, Part 441, section 441.153(a). The independent team may not include anyone who is related, in any way, to the admitting facility, or who is directly responsible for the care of patients whose care is being reviewed or has a financial interest in the admitting facility. The department performs the functions of the independent team;
(11) "Individual plan of care" or "plan of care" means a written plan that meets the criteria set forth in 42 CFR, Part 441, Section 441.155;
(12) "Inpatient" means "inpatient" as defined in 42 CFR, Part 440, section 440.2;
(13) "Interdisciplinary team" means a team that meets the requirements set forth in section 42 CFR, Part 441, section 441.156;
(14) "Medicaid" means the program operated by the department pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act;
(15) "Medical appropriateness" or "medically appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and is the least costly of multiple, equally-effective, alternative treatments or diagnostic modalities;
(16) "Medical necessity" or "medically necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition or to prevent a medical condition from occurring;
(17) "Medical record" means "medical record" as described in 42 CFR, Part 482, section 482.6l and subsection (d) of section 19-13-D3 of the Regulations of Connecticut State Agencies;
(18) "Overnight pass" means a conditional release to the client's proposed residence on discharge of not more than two days duration, after admission and prior to the day of discharge, in which the client has been permitted by the attending physician to be absent from the facility premises and in accordance with the client's treatment needs and goals as specified in the plan of care;
(19) "Provider" means a PRTF that is enrolled in Medicaid;
(20) "Provider agreement" means the signed, written contractual agreement between the department and the provider;
(21) "Psychiatric emergency" means a sudden onset of a psychiatric condition, as determined by a physician, that manifests itself by acute symptoms of such severity that the absence of immediate medical care and treatment in an inpatient psychiatric facility could reasonably be expected to result in serious dysfunction, disability or death of the client or harm to self or another person by the client. Court commitments and clients admitted on a physician emergency certificate are not automatically deemed to qualify as a psychiatric emergency;
(22) "Psychiatric Residential Treatment Facility" or "PRTF" means a facility that meets all the requirements in 42 CFR Part 441, Subpart D and 42 CFR Part 483, Subpart G;
(23) "Quality of care" means the evaluation of medical care to determine if it meets the professionally recognized standard of acceptable medical care for the condition and the client under treatment;
(24) "Retrospective review" means the review conducted after services are provided to a client, to determine the medical necessity, medical appropriateness and quality of the services provided;
(25) "Transfer" means that a client is discharged from a PRTF and directly admitted to another;
(26) "Under the direction of a physician" means that health services may be provided by allied health professionals or paraprofessionals whether or not the physician is physically present at the time that the services are provided; and
(27) "Utilization management" means the prospective, retrospective or concurrent assessment of the medical necessity and appropriateness of the allocation of health care resources and services given, or proposed to be given, to a client.