Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 435.000 - Chronic Disease And Rehabilitation Inpatient Hospital Services › Section 435.402 - Definitions

Current through Register 1525, July 5, 2024
The following terms used in
				130 CMR 435.000 shall have
				the meanings given in 130 CMR 435.402 unless the context clearly requires a
				different meaning.
Abuse
- a nonaccidental 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.
Administrative Day
- a day of
				hospitalization on which a member's care needs can be met in a setting other
				than a chronic-disease or rehabilitation hospital, as defined in 130 CMR
				435.402, and on which a member is clinically ready for discharge.
Admission Screening
- screening prior
				to hospital admission.
Agent
- the Peer Review Organization
				(PRO), the hospital's utilization-review coordinator, or other party designated
				by the Division to act on its behalf in instances when the Division itself does
				not perform the required function.
Chronic-Disease Hospital
- a facility,
				or a unit within a facility, with a majority of its beds licensed by the
				Massachusetts Department of Public Health to provide chronic-disease
				services.
Concurrent Review
- the assessment of
				the medical necessity for continued hospital stay and for all services provided
				during such continued stay. Such review may be performed at any time subsequent
				to the member's admission.
Conversion
- the assumption by the
				Division of responsibility for the health-care coverage of a patient who was
				receiving health-care coverage from a payer other than the Division at the time
				of hospital admission.
Conversion Screening
- screening prior
				to conversion.
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.
Discharge Planner
- a registered nurse
				or a social worker who is licensed, or who is eligible for licensure and has
				submitted an application for licensure to the appropriate Massachusetts board
				of registration or licensing agency in its state, and 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.
Leave-of-Absence Day
- a day during
				which a bed in a 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.
Managed-Care Per Diem
- a daily,
				all-inclusive fee, after deductions for the patient-paid amount and any
				third-party payments, paid monthly by the Division for managed-care
				services.
Managed-Care Program
- a program under
				which a chronic-disease or rehabilitation hospital, for a per diem rate paid
				monthly by the Division, provides or arranges and pays for all managed-care
				services provided to all inpatients who are MassHealth members and who
				participate in the hospital's managed-care program in accordance with the terms
				and conditions stated in the provider agreement between the Division and the
				hospital.
Managed-Care Services
- those services
				mandated by the Massachusetts Department of Public Health as a prerequisite for
				chronic-disease and rehabilitation bed licensure pursuant to
				105 CMR
				130.000, and all other services covered by MassHealth,
				except for acute-level days in an acute hospital.
Massachusetts Department of Public Health
				Hospital
- a facility administered or supervised by the
				Massachusetts Department of Public Health.
Medical Absence
- an absence from a
				chronic-disease or rehabilitation hospital that begins on the day a member is
				transferred to an acute inpatient hospital.
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 shall be 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 shall not be a medical leave-of-absence day.
Medicare Hospital Level of Care
- a
				level of care that meets all criteria, as determined by the Health Care
				Financing Administration or its agent, for Medicare reimbursement for hospital
				care.
Neglect
- failure by a financially
				able caretaker legally 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 providing adequate food, clothing, shelter, education,
				medical care, proper supervision, and guardianship 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 and certification requirements
				of 130 CMR 456.005 or 456.006.
Reasonable Distance
- generally, 25
				miles from the home or usual noninstitutional residence of the member,
				provided, however, that greater distances may be considered reasonable under
				certain circumstances, including but not limited to those where:
(1) the residence is in a rural area;
(2) the member has no family or regular visitors; or
(3) the member requires specialized services only available at
				facilities located at greater distances.
Rehabilitation Hospital
- a facility,
				or a unit within a facility, devoted to the provision of comprehensive services
				to patients whose handicaps are primarily physical, coordinated with efforts to
				minimize the patient's mental, social, and vocational disadvantages. The course
				of treatment is limited to the period in which the member continues to make
				progress toward his or her treatment goal, as described in the member's service
				plan.
Screening
- the assessment of the
				medical necessity for a hospital admission or continued stay.
Utilization-Review Coordinator
- an
				individual responsible for utilization review in a hospital.
Working Days
- Monday through Friday
				except for legal holidays.