Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.402 - Definitions

Current through Register 1525, July 5, 2024
The following terms used in
				130 CMR 415.000 have the
				meanings given in 130 CMR 415.402 unless the context clearly requires a
				different meaning. The reimbursability of services defined in 130 CMR 415.402
				is not determined by these definitions, but by application of regulations
				elsewhere in
				130 CMR 415.000, and in
				130 CMR 410.000:
Acute Outpatient Hospital Services
and 450.000:
Administrative and Billing Regulations
.
Abuse
-- a non-accidental physical
				injury to an individual inflicted by another person that causes or creates a
				substantial risk of death or protracted impairment of any bodily organ or
				function; or the commission of sex offenses against an individual, as defined
				in the criminal laws of Massachusetts.
Acute Inpatient Hospital
-- a facility
				that is licensed as a hospital by the Massachusetts Department of Public Health
				and that provides diagnosis and treatment for patients who have any of a
				variety of medical conditions requiring daily physician intervention as well as
				full-time availability of physician services; however, this does not include
				any facility that is licensed as a chronic disease and rehabilitation hospital,
				any hospital that is licensed primarily to provide mental health services, or
				any unit of a facility that is licensed as a nursing facility, a chronic
				disease unit, or a rehabilitation unit.
Administrative Day
-- a day of
				inpatient hospitalization on which a member's care needs can be provided in a
				setting other than an acute inpatient hospital as defined in 130 CMR 415.402
				and on which a member is clinically ready for discharge.
Agent
-- a party designated by the
				MassHealth agency to act on its behalf in instances when the MassHealth agency
				itself does not perform the required function.
Child and Adolescent Needs and Strengths
				(CANS)
- a tool that provides a standardized way to organize
				information gathered during behavioral-health clinical assessments. A
				Massachusetts version of the tool has been developed and is intended to be used
				as a treatment decision support tool for behavioral-health providers serving
				MassHealth members under 21 years of age.
Cosmetic Surgery
-- a surgical
				procedure that is performed for the exclusive purpose of altering appearance
				and is unrelated to disease or physical defect, or traumatic injury.
Day of Discharge
-- the day on which a
				member leaves the hospital, regardless of the hour. The day of death is also
				considered the day of discharge. A leave-of-absence is not considered a
				discharge.
Discharge Planner
-- a registered
				nurse or a social worker either licensed or eligible for and in the process of
				applying for licensure by the Commonwealth of Massachusetts whose primary
				responsibility is discharge planning.
Discharge-planning
-- the coordinated
				effort of the discharge-planning staff of a hospital to locate appropriate
				placement for members who no longer require hospitalization.
DMH-licensed Bed
- a bed in an acute
				inpatient hospital that is located in a unit licensed by the Department of
				Mental Health (DMH), pursuant to
				104 CMR 27.00:
Licensing and Operational Standards for Mental Health
				Facilities
.
Hysterectomy
- a medical procedure or
				operation for the purpose of removing the uterus.
Inpatient Admission
-- the admission
				of a member to an acute inpatient hospital for the purposes of receiving
				inpatient services in that hospital.
Inpatient Services
-- medical services
				provided to a member admitted to an acute inpatient hospital.
Institutionalized Individual
- an
				individual who is
(1) involuntarily confined or detained, under a civil or
				criminal statute in a correctional or rehabilitative facility, including a
				psychiatric hospital or other facility for the care and treatment of mental
				illness; or
(2) confined, under a voluntary commitment, in a psychiatric
				hospital or other facility for the care and treatment of mental illness.
Leave of Absence Day
-- a day during
				which a bed in an acute inpatient hospital is reserved for a member who leaves
				the facility and for whom no formal discharge and readmission procedures
				occur.
Length of Stay
-- the duration of a
				member's inpatient hospital stay at a Medicare hospital level of care during a
				medical leave of absence.
Medical Leave of Absence
-- an
				inpatient hospital stay of a member who is a resident of a nursing facility for
				up to ten consecutive days in a hospital at a Medicare hospital level of care.
				The day on which a member is transferred from a nursing facility to a hospital
				for an inpatient stay is the first day of the medical leave of absence from the
				nursing facility. The day on which a member is transferred from a hospital back
				to a nursing facility or is otherwise discharged to a noninstitutional setting
				is not a medical leave of absence day.
Medicare Hospital Level of Care
-- a
				level of care that meets all criteria, as determined by the Centers for
				Medicare and Medicaid Services or its agent, for Medicare reimbursement for
				hospital care.
Mentally Incompetent Individual
- an
				individual who has been declared mentally incompetent by a federal, state, or
				local court of competent jurisdiction for any purpose, unless the individual
				has been declared competent for purposes that include the ability to consent to
				sterilization.
Neglect
-- failure by a financially
				able caretaker responsible for an individual to provide adequate food,
				clothing, shelter, education, medical care, proper supervision, or guardianship
				that results in the individual's present avoidable suffering. The caretaker is
				considered capable of adequately providing these necessities if the caretaker
				is financially able to do so or is offered other reasonable means to do
				so.
Nursing Facility
-- a long-term-care
				institution that meets the provider eligibility requirements of 130 CMR
				456.004:
Requirements for Provider Participation: In-state
or
				456.005:
Requirements for Provider Participation: Out-of-state
and the certification requirements of
				130 CMR
				456.406:
Medicare Certification
				Requirement
.
Observation Services
-- outpatient
				hospital services provided anywhere in an acute inpatient hospital, to evaluate
				a member's condition and determine the need for admission to an acute inpatient
				hospital. Observation services are provided under the order of a physician,
				consist of the use of a bed and intermittent monitoring by professional
				licensed clinical staff, and may be provided for more than 24 hours.
Outpatient Hospital Services
--
				medical services provided to a member in a hospital outpatient department. Such
				services include, but are not limited to, emergency services, primary-care
				services, observation services, ancillary services, day-surgery services, and
				recovery-room services.
Outpatient Services
-- medical
				services provided to a member in an outpatient setting including but not
				limited to hospital outpatient departments, hospital-licensed health centers,
				physicians' offices, nurse practitioners' offices, freestanding ambulatory
				surgery centers, day treatment centers, or the member's home.
Reasonable Distance
-- generally, 25
				miles from the home or usual noninstitutional residence of the member. This
				definition does not preclude longer distances in such instances as, but not
				limited to, rural areas or in cases where the member has no family or regular
				visitors.
Reconstructive Surgery
-- a surgical
				procedure that is performed to correct, repair, or ameliorate the physical
				effects of disease or physical defect (for example, correction of a cleft
				palate), or traumatic injury.
Sterilization
- any medical procedure,
				treatment, or operation for the purpose of rendering an individual permanently
				incapable of reproducing.
Utilization Review Coordinator
-- an
				individual responsible for utilization review in a hospital.
Working Days
-- Monday through Friday
				except for legal holidays.