Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 160 - Medicaid Program; General Provisions › Article 3 - General Provisions › 7 AAC 160.990 - Definitions

Current through May 31, 2024
(a) In the definition of "health facility" in
				  AS
				  47.07.900, "outpatient surgical clinic" means
				  an ambulatory surgical center.
(b)
				  In 7 AAC 105 - 7 AAC 160, unless the context requires otherwise,
(1) "Alaska Native" has the meaning given
				  "Native" in  43 U.S.C. 1602(b);
(2)
				  "ambulatory surgical center" has the meaning given in
				  AS
				  47.32.900;
(3) "American Indian" has the meaning given
				  "Indian" in  25 U.S.C. 479;
(4)
				  "claim" means a request for payment submitted to the department, on paper or
				  electronically, by a Medicaid provider who has provided a service to a
				  recipient under 7 AAC 105 - 7 AAC 160;
(5) "clinical social worker" means an
				  individual licensed as a clinical social worker under AS 08.95;
(6) "CMS" means the United States Department
				  of Health and Human Services, Centers for Medicare and Medicaid
				  Services;
(7) "community mental
				  health clinic" means a program
(A) headed by
				  a
(i) physician, who may be a psychiatrist;
				  or
(ii) psychologist or mental
				  health professional clinician working under the general direction of a
				  physician;
(B) that
				  provides mental health services; and
(C) operates
(i) under 7 AAC 71; or
(ii) as a state-operated community mental
				  health clinic;
(8) "continued stay" mean a stay in a
				  facility that is uninterrupted by a discharge and readmission;
(9) "covered" or "coverage" means the
				  department pays for all or part of that service as a Medicaid service under
				  AS
				  47.07.030 and 7 AAC 105 - 7 AAC
				  160;
(10) repealed
(11) "crisis intervention" means short-term
				  mental health services provided to a recipient during an acute episode of a
				  mental, emotional, or behavioral disorder, that are intended to reduce the
				  symptoms of the disorder, prevent harm to the recipient or others, prevent
				  further relapse or deterioration of the recipient's condition, or stabilize the
				  recipient;
(12) "department" means
				  the Department of Health and Social Services;
(13) "dispensing provider" means one of the
				  following entities, if that entity dispenses drugs as part of a medical
				  practice, does not employ a pharmacist to dispense drugs, and is not enrolled
				  with Medicaid as an outpatient pharmacy:
(A) a
				  physician;
(B) a
				  podiatrist;
(C) a physician
				  assistant;
(D) an advanced practice
				  registered nurse;
(E) a rural
				  health clinic that meets the requirements of
				  7 AAC 140.210;
(F) a federally qualified health center that
				  meets the requirements of
				  7 AAC 140.205;
(G) a tribal health program;
(14) "EPSDT" means the early
				  periodic screening, diagnosis, and treatment program under Medicaid;
(15) "estate" has the meaning given in
				  AS
				  13.06.050;
(16) "facility" means
(A) a general acute care hospital;
(B) a specialty hospital; in this
				  subparagraph, "specialty hospital" has the meaning given in
				  7 AAC 150.990;
(C) a nursing facility;
(D) an intermediate care facility for the
				  mentally retarded;
(E) an inpatient
				  psychiatric hospital;
(F) a rural
				  health clinic;
(G) a federally
				  qualified health center;
(H) an
				  ambulatory surgical center;
(I) a
				  home health agency, except that in 7 AAC 150, "facility" does not include a
				  home health agency; or
(J) a
				  residential psychiatric treatment center, except that in 7 AAC 150, "facility"
				  does not include a residential psychiatric treatment center;
(K) an end-stage renal disease
				  facility;
(17) "family
				  psychotherapy" means a form of therapy in which members of a family or any two
				  or more individuals sharing a household, one of whom is a Medicaid recipient,
				  attend psychotherapy sessions together for the treatment of relationships
				  within the family or household to achieve better emotional, behavioral, or
				  social adjustments of all the individuals within the family or
				  household;
(18) "federal and state
				  laws" means laws of the United States government and laws of a jurisdiction of
				  the United States;
(19) "federally
				  qualified health center" means a facility that has filed an agreement with the
				  department to provide federally qualified health center services under
				  Medicaid;
(20) "fiscal agent" means
				  an organization that processes and pays provider claims on behalf of the
				  department;
(21) "freestanding
				  facility" means a facility that is individually licensed and enrolled to
				  provide health care services independent from administrative or financial
				  control of another facility;
(22)
				  "functional assessment" means a systematic evaluation of a recipient to assess
				  that recipient's functioning level in the areas of living skills, learning,
				  education, work, interpersonal skills, and other life skills necessary for
				  independent living, in order to develop an individualized written treatment
				  plan;
(23) "general acute care
				  hospital" has the meaning given in
				  7 AAC 12.990;
(24) "group practice" means a legally
				  organized partnership, professional corporation, foundation, nonprofit
				  corporation, or similar association comprised of one or more health care
				  providers;
(25) "group skill
				  development services" means face-to-face therapeutic skill instruction, skill
				  practice, and skill monitoring, offered in a group setting, designed to help
				  the recipient develop or improve specific self-care, self-direction,
				  communication, or social-interaction skills necessary for successful community
				  adjustment and interaction with persons in the recipient's home, school, work,
				  or community environment;
(26)
				  "home and community-based waiver services" means services provided under
				  AS
				  47.07.045 and 7 AAC 130;
(27) "home and community-based waiver
				  services provider" means a provider that the department has certified under
				  7 AAC 130.220 to provide one or more home and
				  community-based waiver services;
(28) "hospice care" has the meaning given in
				  AS
				  47.07.900;
(29) "hospital" means a facility licensed by
				  the department under 7 AAC 12 to provide inpatient and outpatient hospital
				  services;
(30) "ICF" means an
				  intermediate care facility;
(31)
				  "ICF/MR" means an intermediate care facility for the mentally
				  retarded;
(32) "individual
				  psychotherapy" means any form of treatment for mental illness, behavioral
				  maladaptation, or other problems that are assumed to be of an emotional nature,
				  in which a trained individual deliberately establishes a professional
				  relationship with an individual for the purpose of removing, modifying, or
				  retarding existing symptoms, attenuating or reversing disturbed patterns of
				  behavior, and promoting positive personality growth and development;
(33) "individual skill development services"
				  means face-to-face therapeutic self-care and life skill instruction, skill
				  practice, and skill monitoring, provided to an individual, and designed to help
				  the recipient develop or improve specific self-care skills, engage in
				  age-appropriate social behavior, maintain the recipient's household, and
				  develop the ability to be independent within the recipient's
				  community;
(34) "inpatient
				  interdisciplinary team" means a team composed of physicians and other personnel
				  who are employed by an inpatient psychiatric hospital facility, a residential
				  psychiatric treatment center, or an individual who renders services to
				  recipients in either facility;
(35)
				  "inpatient psychiatric hospital" means a hospital or part of a hospital, other
				  than a residential psychiatric treatment center, that delivers medical and
				  inpatient psychiatric services described in
				  7 AAC 12.215;
(36) "inpatient psychiatric services" means
				  diagnostic and treatment services for mental, behavioral, and emotional
				  disorders provided in an inpatient psychiatric hospital that meets the
				  conditions for payment under
				  7 AAC 140.350, or provided in a residential psychiatric
				  treatment center that meets the conditions for payment under
				  7 AAC 140.400;
(37) "intake assessment" means a systematic
				  evaluation of a recipient upon admission to services, and periodically during
				  the course of treatment, to assess and document mental status, social and
				  medical history, the presenting problems and related symptoms, the recipient's
				  strengths and resources, and service needs of the recipient for the purposes of
				  establishing a diagnosis and developing an individualized treatment
				  plan;
(38) "intermediate care
				  facility" means a nursing facility that provides intermediate care services
				  described in
				  7 AAC 140.510; "intermediate care facility" does not
				  include an intermediate care facility for the mentally retarded;
(39) "intermediate care facility for the
				  mentally retarded" means a facility, or a distinct part of one, that
(A) is licensed under AS 47.32;
(B) is primarily for the diagnosis,
				  treatment, or rehabilitation of the mentally retarded or persons with related
				  conditions; and
(C) has met the
				  conditions for payment under
				  7 AAC 140.600;
(40) "jurisdiction" means a state or
				  territory of the United States and the District of Columbia;
(41) "legend drug" has the meaning given in
				  AS
				  08.80.480;
(42) "long-term care" means
(A) services provided in a nursing
				  facility;
(B) services provided in
				  an intermediate care facility for the mentally retarded;
(C) home and community-based waiver services;
				  or
(D) any other services received
				  in a medical institution by a recipient who is an institutionalized individual
				  required to pay a portion of that individual's income toward the cost of care
				  under 7 AAC 100.550 -
				  7 AAC 100.579;
(43) "long-term care facility" means an
				  intermediate care facility for the mentally retarded or a nursing
				  facility;
(44) "Medicaid" means the
				  medical assistance program administered by the department under  42 U.S.C. 1396- 1396  v and AS 47.07, including those eligibility groups and services for which
				  additional federal financial participation is available under  42 U.S.C. 1397 aa;
(45) "medical institution" has
				  the meaning given in
				  7 AAC 100.990;
(46) "Medicare" means the medical assistance
				  program administered by the federal government through private health insurance
				  companies under  42 U.S.C. 1395- 1395  iii;
(47) "Medicare cost report" means the uniform
				  cost report that a facility must prepare under
				  42 C.F.R.
				  413.20-
				  413.24;
(48) repealed 10/1/2011;
(49) "mental health professional clinician"
				  means
(A) an individual who
(i) is working for an enrolled community
				  behavioral health services provider;
(ii) is performing community behavioral
				  health services that are within that individual's field of expertise;
(iii) is not working in a capacity that
				  requires the individual to be licensed under AS 08; and
(iv) has a master's degree or more advanced
				  degree in psychology, counseling, child guidance, community mental health,
				  marriage and family therapy, social work, or nursing;
(B) a nurse who
(i) has a master's degree in
				  nursing;
(ii) has received special
				  training or experience in mental health;
(iii) has an active license to practice
				  nursing issued by the jurisdiction in which the nurse provides services, or if
				  services are provided in this state, holds an active license under AS 08.68;
				  and
(iv) is working in the
				  individual's field of expertise;
(C) a marital and family therapist who
(i) has an active license to practice marital
				  and family therapy issued by the jurisdiction in which the marital and family
				  therapist provides services, or if services are provided in this state, holds
				  an active license under AS 08.63; and
(ii) is working in the individual's field of
				  expertise;
(D) a
				  professional counselor who
(i) has an active
				  license to practice as a professional counselor issued by the jurisdiction in
				  which the professional counselor provides services, or if services are provided
				  in this state, holds an active license under AS 08.29; and
(ii) is working in the individual's field of
				  expertise;
(E) a social
				  worker who
(i) has a master's degree in
				  social work;
(ii) has an active
				  license to practice as a social worker issued by the jurisdiction in which the
				  social worker provides services, or if services are provided in this state,
				  holds an active license under AS 08.95; and
(iii) is working in the individual's field of
				  expertise; or
(F) a
				  psychologist or psychological associate who
(i) has an active license to practice as a
				  psychologist or psychological associate issued by the jurisdiction in which the
				  psychologist or psychological associate provides services, or if services are
				  provided in this state, holds an active license under AS 08.86; and
(ii) is working in the individual's field of
				  expertise;
(50) "nursing facility" has the meaning given
				  in AS
				  18.20.390; "nursing facility" includes a
				  skilled nursing facility and an intermediate care facility;
(51) "part A of Medicare" means that portion
				  of the Medicare program providing coverage for hospital care under  42 U.S.C. 1395  c - 1395i-5;
(52) "patient"
				  means an individual who receives medical attention, care, or
				  treatment;
(53) "person" has the
				  meaning given in
				  AS
				  01.10.060; "person" includes a municipality
				  and the state;
(54) repealed
				  10/1/2011;
(55) "physiatrist" means
				  a physician who specializes in that branch of medicine using physical therapy,
				  physical agents, such as light, heat, water, and electricity, and mechanical
				  apparatus, in the diagnosis, prevention, and treatment of bodily disorders
				  known as physiatrics;
(56)
				  "prescription drug" has the meaning given in
				  AS
				  08.80.480;
(57) "primary care" means the provision of
				  professional comprehensive health services that includes health education and
				  disease prevention, initial assessment of health problems, treatment of acute
				  and chronic health problems, and the overall management of an individual's or
				  family's health care services;
(58)
				  "prior authorization" means approval by the department, in accordance with
				  7 AAC 105.130 and service-specific requirements in 7 AAC
				  105 - 7 AAC 160, of a certain type and number of units of Medicaid-covered
				  services before those services are provided;
(59) "provider" means an individual, firm,
				  corporation, association, or institution that provides, medical assistance to a
				  recipient under Medicaid;
(60)
				  "psychiatric assessment" means a systematic evaluation of a recipient to
				  determine symptomatology, establish a diagnosis, and prescribe needed
				  treatment;
(61) "psychiatric
				  facility" means a licensed hospital facility or part of a licensed hospital
				  facility that is primarily for the diagnosis and treatment of mental,
				  emotional, or behavioral disorders;
(62) "psychiatrist" means a physician
				  licensed to practice medicine in the jurisdiction in which services are
				  provided, and who has completed a fully qualified residency in
				  psychiatry;
(63) "psychological
				  associate" means an individual licensed in the jurisdiction in which services
				  are provided, who renders specific mental health services in association with a
				  licensed psychologist within the scope of practice identified in
				  12 AAC 60.185;
(64) repealed 10/1/2011;
(65) "psychologist" means an individual who
				  is licensed to practice psychology in the jurisdiction in which services are
				  provided;
(66) "psychosocial
				  assessment" has the meaning given in this section for "functional
				  assessment";
(67) "quality
				  improvement organization" or "QIO" means an organization that has a contract
				  with the Department of Health and Human Services, Centers for Medicare and
				  Medicaid Services, under part B of title XI of the Social Security Act,  42 U.S.C. 1320  c - 1320c-12, to perform utilization and quality control review of
				  the health care furnished, or to be furnished, to Medicare beneficiaries, and
				  operates under a contract with the state to provide preadmission screening and
				  utilization review services;
(68)
				  "RBRVS" means resource-based relative value scale;
(69) "recipient" means an individual who has
				  been determined eligible for Medicaid in this state, including home and
				  community-based waiver services, and who is receiving, is authorized to
				  receive, or has received a Medicaid-covered service from a provider enrolled in
				  the Medicaid program in this state;
(70) "recipient's representative" means a
				  parent, guardian, or other individual with legal authority to act on the
				  recipient's behalf;
(71)
				  "recoupment" means an action by the department to recover an overpayment by
				  reducing future payments to the provider until the amount of the overpayment
				  has been offset;
(72) "rendering
				  provider" means a provider whose direct services are paid through a health care
				  provider enrolled under
				  7 AAC 105.200(a);
(73) "residential care" means a residential
				  living arrangement that provides a structured setting with supervision and care
				  where the needs of the residents are largely social; a facility providing
				  residential care is one that offers
(A)
				  shelter, food, household maintenance, encouragement, and assistance to the
				  residents;
(B) guidance as
				  necessary in activities of daily living;
(C) social and recreational activities and
				  opportunities; and
(D) arrangements
				  made to secure medical services when the need is indicated;
(74) "residential psychiatric
				  treatment center" means a freestanding facility that
(A) provides residential child care and
				  inpatient psychiatric services for the diagnosis and treatment of child and
				  adolescent mental, emotional, or behavioral disorders;
(B) is licensed under AS 47.32;
(C) meets the requirements of
				  7 AAC 140.400; and
(D) is not a provider eligible for payment
				  under 7 AAC 150;
(75)
				  "respite care" means care provided to an individual for the purpose of relief
				  of family members or other regular care providers in the home, except for
				  personal care assistants;
(76)
				  "rural health clinic" means a facility that has filed an agreement with the
				  department to provide rural health clinic services under Medicaid;
(77) "RVU" means relative value
				  unit;
(78) "service" means a
				  medical evaluation or procedure, drug, medical supply, item, equipment,
				  transportation, or other benefit related to an individual's health or delivery
				  of health care;
(79) "skilled
				  nursing facility" has the meaning given in  42 U.S.C. 1395i-3(a);
(80) "SNF" means a skilled nursing
				  facility;
(81) "tribal health
				  program" means a hospital, clinic, or other type of health care facility or
				  program operated by
(A) the United States
				  Department of Health and Human Services, Indian Health Service;
(B) an Indian tribe as defined in  25 U.S.C. 450  b(e) and 458aaa(b);
(C) a
				  tribal organization as defined in  25 U.S.C. 450  b (
l
);
				  or
(D) an inter-tribal consortium
				  as defined in  25 U.S.C. 458  aaa(a)(5) or established by federal law;
(82) "utilization review" means
				  the process of evaluating the appropriateness and efficient use of medical
				  services and facilities, including admission criteria, length of stay, and
				  discharge practices;
(83) "skilled
				  nursing visit" means a personal visit by a nurse to perform a level of care or
				  treatment that requires the nurse to be licensed in the jurisdiction in which
				  services are provided;
(84)
				  "national drug code" or "NDC" means the code assigned by the United States Food
				  and Drug Administration under  21 C.F.R. Part 207  (registration of producers of
				  drugs and listing of drugs in commercial distribution);
(85) repealed 6/16/2016;
(86) "behavioral health clinical associate"
				  means an individual
(A) who has less than a
				  master's degree in psychology, social work, counseling, or a related field with
				  specialization or experience in providing rehabilitation services to recipients
				  with severe behavioral health conditions;
(B) whose responsibilities may include
				  provision of psychosocial evaluation, education related to a recipient's
				  behavioral health condition, encouraging and coaching, counseling, and teaching
				  of needed life skills; and
(C) who
				  works within the scope of the individual's training, experience, and
				  education;
(87)
				  "behavioral health services" means the behavioral health clinic services
				  identified in
				  7 AAC 135.010(b) and the behavioral
				  health rehabilitation services identified in
				  7 AAC 135.010(c);
(88) repealed 6/16/2016;
(89) "community behavioral health services
				  provider" has the meaning given in
				  7 AAC 70.990;
(90) "counseling" means an exchange of
				  information, opinions, and ideas between the recipient and the recipient's
				  provider about the recipient's life choices and behaviors for the purpose of
				  helping the recipient make positive changes in the recipient's
				  behavior;
(91) "detoxification"
				  means the immediate physiological stabilization, diagnosis, and treatment of a
				  recipient who is intoxicated, incapacitated, or experiencing withdrawal from
				  using alcohol or drugs;
(92)
				  "functional impairment"
(A) means a disorder
				  that substantially interferes with or prevents a recipient from achieving or
				  maintaining one or more developmentally appropriate social, behavioral,
				  cognitive, communicative, or adaptive skills;
(B) includes disorders of episodic,
				  recurrent, or continuous duration;
(C) does not include temporary, expected
				  responses to stressful events in the recipient's environment;
(93) "group psychotherapy" means a
				  form of psychotherapy in which two or more individuals participate together in
				  the presence of one or more psychotherapists;
(94) "mental, emotional, or behavioral
				  disorder" means a disorder identified by a provider listed in
				  7 AAC 135.030 and in accordance with the
(A)
Diagnostic and Statistical Manual
				  of Mental Disorders
, adopted by reference in
				  7 AAC 160.900;
(B)
International Classification of
				  Diseases
, adopted by reference in
				  7 AAC 160.900; or
(C)
Diagnostic Classification of
				  Mental Health and Developmental Disorders of Infancy and Early Childhood:
				  Revised Edition (DC:0-3R)
, adopted by reference in
				  7 AAC 160.900;
(95) "mental health physician clinic" means a
				  clinic, operated by one or more psychiatrists, that exclusively or primarily
				  provides mental health clinic services furnished by a psychiatrist or by one or
				  more of the professionals identified in
				  7 AAC 135.030(d) (2);
(96) repealed 4/9/2017
(97) "neuropsychological testing" means the
				  administration of specific psychological tests that are designed to measure and
				  identify cognitive impairments that may be the result of brain
				  damage;
(98) "psychotherapy" means
				  the treatment of a mental, emotional, or behavioral disorder through the use of
				  psychological techniques;
(99)
				  "recipient's residence"
(A) means the
				  physical location where the recipient conducts the daily activities of sleeping
				  and storage of personal possessions, whether temporary or permanent, regardless
				  of recipient ownership;
(B)
				  includes a dwelling maintained by a public or private support organization or
				  an assisted living home;
(100) "severe behavioral health disorder"
				  means an individual
(A) has a substance use
				  disorder;
(B) is a child
				  experiencing a severe emotional disturbance; or
(C) is an adult experiencing a serious mental
				  illness;
(101)
				  "substance abuse" means a maladaptive pattern of substance use manifested by
				  recurrent and significant adverse consequences related to the repeated use of
				  substances;
(102) "substance use
				  disorder" means a disorder that is identified by a diagnostic code found in the
				  American Psychiatric Association's
Diagnostic and Statistical Manual of
				  Mental Disorders
, adopted by reference in
				  7 AAC 160.900, and that is related to
(A) alcohol, amphetamine, or similar acting
				  sympathomimetics;
(B) cannabis,
				  cocaine, hallucinogens, inhalants, nicotine, or opioids;
(C) analogs of phencyclidine (PCP) or similar
				  arylcyclohexylamines; or
(D)
				  sedatives, hypnotics, or anxiolytics;
(103) "urinalysis" means laboratory testing
				  of a recipient's urine performed by a laboratory accredited under  42 C.F.R.
				  Part 493 ;
(104) "Medicare Part B"
				  means that portion of the Medicare program providing coverage for physician and
				  outpatient care under  42 U.S.C. 1395  j - 1395w-5.
(105) "FDA" means the United States Food and
				  Drug Administration.
(106) "opioid
				  use disorder treatment program" means an individual or entity that
(A) administers or dispenses a narcotic drug
				  to a narcotic addict for withdrawal or maintenance treatment;
(B) provides to individuals when appropriate
				  or necessary a comprehensive range of medical and behavioral health clinical
				  and rehabilitative services; and
(C) is approved under 7 AAC 70.
(107) "background check" means the
				  processing of an individual's fingerprints, name, social security number, and
				  other identifying information as described in
				  7 AAC 10.915.
(108) "Community First Choice personal care
				  services" means personal care services provided under 7 AAC 127;
(109) "Community First Choice services" means
				  personal care services and other services provided under 7 AAC 127.
(110) repealed 11/10/2019.
(111) "1115 waiver" means the Substance Use
				  Disorder and Behavioral Health Program demonstration approved by the United
				  States Department of Health and Human Services. Centers for Medicare and
				  Medicaid Services as a section 1115 waiver under  42 U.S.C. 1315(a).