Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1 - General Provisions › Section 1-1 - Definitions

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 4-6-10; IC 12-13-7-3; IC 12-15; IC 16-19; IC
				  16-21; IC 16-28; IC 16-29-4-2
Sec. 1.
The following definitions in this section apply throughout
				  this article:
(1) "Attending
				physician" means a physician who is responsible for developing and maintaining
				the plan of care for a Medicaid patient.
(2) "CMS" means the Centers for Medicare and
				Medicaid Services, a federal agency within the United States Department of
				Health and Human Services.
(3)
				"CRF/DD" or "CRFs/DD" means a community residential facility or facilities for
				the developmentally disabled.
(4)
				"CRMNF" means a comprehensive rehabilitative management needs facility as
				defined in
				460 IAC 9-1-2.
(5) "ICF/IID" or "ICFs/IID" means an
				institution or institutions for individuals with intellectual disabilities, as
				described in IC 16-29-4-2, or a medical institution or that portion thereof
				providing such care, which is qualified as such an institution pursuant to the
				provisions of Title XIX of the Social Security Act.
(6) "IMFCU" means the Medicaid fraud control
				unit established by the Indiana attorney general under the authority of IC
				4-6-10.
(7) "ISDH" means the state
				department of health as defined in IC 16-19.
(8) "Medicaid" means that program described
				by IC 12-15 and this title, in which the office administers benefits and makes
				payments to providers for covered services provided to members.
(9) "Member" means an individual who has been
				determined by the office to be eligible for payment of covered services
				pursuant to IC 12-15.
(10) "Nursing
				facility" means a comprehensive care facility licensed under IC 16-28, or a
				hospital based long term care facility licensed under IC 16-21 and enrolled as
				a Medicaid provider.
(11) "Nursing
				facility services" has the meaning set forth in
				405 IAC 5-31-1.1.
(12) "Office" means the Indiana family and
				social services administration and its offices, divisions, or
				designees.
(13) "Parameter" means
				the maximum amount or duration, or both, of a service within appropriate limits
				for which payment may be made without prior authorization or exception due to
				medical necessity or contraindications.
(14) "Prior authorization" has the meaning
				set forth in
				405 IAC 5-2-20.
(15) "Provider" means an individual, state
				agency, local agency, corporate entity, or business entity that has been
				enrolled in Medicaid pursuant to
				405 IAC 1-1.4-3.
(16) "Provider manual" means the interpretive
				document or documents issued by the office to providers to inform them of their
				obligations under Medicaid to which they must conform to retain their provider
				status and receive payment for appropriate services, and to provide them
				essential information for understanding Medicaid as it relates to the services
				for which they are qualified to provide under the state statutes.
(17) "Third party" means an insurer,
				individual, institution, corporation, or public or private agency who is or may
				be liable to pay all or part of the medical costs of injury, disease, or
				disability of an applicant or recipient of Medicaid. (18) "Usual and customary
				charge" means the amount a provider offers to charge the general public for a
				service or supply, including applicable offered discounts. General public does
				not include individuals who are enrolled in or a member of an insurance plan
				that covers the services or supplies in question, or receive a discount of the
				services or supplies through a program with selective criteria that disqualify
				certain individuals from eligibility in the program.
Transferred from the Division of Family and Children
					 (470 IAC 5-1-1) to the Office of
					 the Secretary of Family and Social Services (405 IAC
					 1-1-1) by
					 P.L.
					 9-1991,
					 SECTION
					 131, effective January 1,
					 1992.