North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-03.2 - Definitions

Current through Supplement No. 393, July, 2024
For purposes of this chapter:
1. "Certification of need" means a regulatory
				review process that requires specific health care providers to obtain prior
				authorization for provision of services for Medicaid applicants or eligible
				recipients under age twenty-one. Certification of need is a determination of
				the medical necessity of the proposed services as required for all applicants
				or recipients under the age of twenty-one prior to admission to a psychiatric
				hospital, an inpatient psychiatric program in a hospital, or a psychiatric
				facility, including a psychiatric residential treatment facility. The
				certification of need evaluates the individual's capacity to benefit from
				proposed services, the efficacy of proposed services, and consideration of the
				availability of less restrictive services to meet the individual's
				needs.
2. "Department" means the
				North Dakota department of health and human services.
3. "Drug use review board" means the board
				established pursuant to North Dakota Century Code chapter 50-24.6.
4. "Enrolled in-state provider" means the
				enrolled medical provider who has assumed responsibility for the advice and
				care of the recipient.
5. "Exercise
				program" includes regimens to achieve various improvements in physical fitness
				and health.
6. "Home health agency"
				means a public or private agency or organization, or a subdivision of such an
				agency or organization, which is qualified to participate as a home health
				agency under title XVIII of the Social Security Act, or is determined currently
				to meet the requirements for participation.
7. "Indian health service or tribal health
				facility or clinic" means either a health service facility or clinic operated
				by the United States department of health and human services Indian health
				service division or a federally recognized tribal nation that has opted to
				contract with Indian health service to plan, conduct, and administer one or
				more individual programs, functions, services, or activities, resulting in
				tribal health facilities or clinics operated by tribes and tribal organizations
				under the Indian Self-Determination and Education Assistance Act [Pub. L.
				93-638].
8. "Licensed practitioner" means an
				individual other than a physician who is licensed or otherwise authorized by
				the state to provide health care services within the practitioner's scope of
				practice.
9. "Medical emergency"
				means a medical condition of recent onset and severity, including severe pain,
				that would lead a prudent layperson acting reasonably and possessing an average
				knowledge of health and medicine to believe that the absence of immediate
				medical attention could reasonably be expected to result in serious impairment
				to bodily function, serious dysfunction of any bodily organ or part, or would
				place the individual's health, or with respect to a pregnant individual, the
				health of the individual or their unborn child, in serious jeopardy.
10. "Medically necessary" includes only
				medical or remedial services or supplies required for treatment of illness,
				injury, diseased condition, or impairment; consistent with the recipient's
				diagnosis or symptoms; appropriate according to generally accepted standards of
				medical practice; not provided only as a convenience to the recipient or
				provider; not investigational, experimental, or unproven; clinically
				appropriate in terms of scope, duration, intensity, and site; and provided at
				the most appropriate level of service that is safe and effective.
11. "Provider" means an individual, entity,
				or facility furnishing medical or remedial services or supplies pursuant to a
				provider agreement with the department.
12. "Psychiatric residential treatment
				facility" is as defined in subsection 13 of section
				75-03-17-01.
13. "Recipient" means an individual approved
				as eligible for Medicaid or children's health insurance program.
14. "Rehabilitative services" means any
				medical or remedial items or services prescribed for a recipient by the
				recipient's physician or other licensed practitioner of the healing arts,
				within the scope of the physician's or practitioner's practice as defined by
				state law, for the purpose of maximum reduction of physical or mental
				disability and restoration of the recipient to the recipient's best possible
				functional level.
15. "Remedial
				services" includes those services, including rehabilitative services, which
				produce the maximum reduction in physical or mental disability and restoration
				of a recipient to the recipient's best possible functional level.
16. "Weight loss program" includes programs
				designed for reduction in weight, but does not include weight loss
				surgery.
General Authority:
NDCC 50-24.1-04
Law Implemented:
NDCC
					 50-24.1-01