Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › DEFINITIONS › Section 1101.21 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this part, have
					 the following meanings, unless the context clearly indicates otherwise:
Adult
-An MA recipient 21 years of age or
					 older.
CRNP
-Certified registered nurse
					 practitioner.
Categorically needy
-Aged, blind or
					 disabled individuals or families and children who are otherwise eligible for
					 Medicaid and who meet the financial eligibility requirements for TANF, SSI or
					 an optional State supplement.
Complete medical history
-A chronological
					 medical record which includes, but is not limited to, major complaints, present
					 medical history, past medical history, family history and social
					 history.
County Assistance Offices
or
CAOs
-The local offices of the Department that administer the
					 MA Program on the local level. They determine recipient eligibility and perform
					 other necessary MA functions such as prior authorization and client referral to
					 a source of medical services.
Covered service
-A benefit to which a MA
					 recipient is entitled under the MA Program of the Commonwealth.
Department
-The Department of Public
					 Welfare of the Commonwealth or a subagency thereof.
Emergency situation
-A condition in which
					 immediate medical care is necessary to prevent the death or serious impairment
					 of health of the individual.
Enroll
-The act of becoming eligible to
					 participate in the MA Program by completing the provider enrollment form,
					 entering into or renewing as required a written provider agreement and meeting
					 other participation requirements specified in this chapter and the appropriate
					 separate chapters relating to each provider type.
EPSDT
-Early and Periodic Screening,
					 Diagnosis and Treatment Program.
FQHC
-Federally qualified health
					 center.
Factor
-An individual or an organization,
					 such as a service bureau, that advances money to a provider for accounts
					 receivable that the provider has assigned, sold or transferred to the
					 individual or organization for an added fee or a deduction of a portion of the
					 accounts receivable.
GA-General Assistance
-MA funded solely by
					 State funds as authorized under Article IV of the Public Welfare Code
					 (62
					 P. S. §§
											401-488).
General public
-Payors other than Medicaid.
					 The term includes other health insurance plans.
HHS
-The United States Department of Health
					 and Human Services or its successor agency, which is given responsibility for
					 implementation of Title XIX of the Social Security Act.
MA
-Medical Assistance.
Medicaid
-Medical Assistance provided under
					 a State Plan approved by HHS under Title XIX of the Social Security Act.
Medical facility
-A licensed or approved
					 hospital, skilled nursing facility, intermediate care facility, intermediate
					 care facility for the mentally retarded, public clinic, shared health facility,
					 rural health clinic, psychiatric clinic, pharmacy, laboratory, drug and alcohol
					 clinic, partial hospitalization facility or family planning clinic.
Medically necessary
-A service, item,
					 procedure or level of care that is:
(i) Compensable under the MA
				  Program.
(ii) Necessary to the
				  proper treatment or management of an illness, injury or disability.
(iii) Prescribed, provided or ordered by an
				  appropriate licensed practitioner in accordance with accepted standards of
				  practice.
Medically needy
-A term used to refer to
					 aged, blind or disabled individuals or families and children who are otherwise
					 eligible for Medicaid and whose income and resources are above the limits
					 prescribed for the categorically needy but are within limits set under the
					 Medicaid State Plan.
Noncompensable item
-A service or supply a
					 provider furnishes for which there is no provision for payment under this
					 part.
Parent/caretaker
-The person responsible
					 for the care and control of an unemancipated minor child. This includes mother
					 or father, grandmother or grandfather, stepmother or stepfather or another
					 relative related by blood or marriage.
Postpartum period
-The period beginning on
					 the last day of the pregnancy and extending through the end of the month in
					 which the 60-day period following termination of the pregnancy ends.
Practitioner
-A medical doctor, doctor of
					 osteopathy, dentist, optometrist, podiatrist, chiropractor or other medical
					 professional licensed by the Commonwealth or by another state who is authorized
					 to participate in the MA Program as a provider.
Prepayment review
-Determination of the
					 medical necessity of a service or item before payment is made to the provider.
					 Prepayment review is performed after the service or item is provided and
					 involves an examination of an invoice and related material, when appropriate.
					 Prepayment review is not prior authorization.
Prior authorization
-A procedure
					 specifically required or authorized by this title wherein the delivery of an MA
					 item or service is either conditioned upon or delayed by a prior determination
					 by the Department or its agents or employees that an eligible MA recipient is
					 eligible for a particular item or service or that there is medical necessity
					 for a particular item or service or that a particular item or service is
					 suitable to a particular recipient.
Professional Standards Review Organization
or
PSRO
-An organization which HHS has charged with the
					 responsibility for operating professional review systems to determine whether
					 hospital services are medically necessary, provided appropriately, carried out
					 on a timely basis and meet professional standards.
Program
-The MA program of the
					 Commonwealth.
Provider
-An individual or medical facility
					 which signs an agreement with the Department to participate in the MA program,
					 including, but not limited to: licensed practitioners, pharmacies, hospitals,
					 nursing homes, clinics, home health agencies and medical purveyors.
Public clinic
-A health clinic operated by
					 a Federal, State or local governmental agency.
Purveyor
-A person other than a
					 practitioner who, directly or indirectly, engages in the business of supplying
					 to patients medical supplies, equipment or services for which reimbursement
					 under the MA program is received, including, but not limited to: clinical
					 laboratory services or supplies, X-ray laboratory services or supplies,
					 inhalation therapy services or equipment, ambulance services, sick room
					 supplies, physical therapy services or equipment, and orthopedic or surgical
					 appliances or supplies.
Recipient
-A person or family that is
					 eligible for MA benefits.
School child
-A child attending a
					 kindergarten, elementary, grade or high school, either public or
					 private.
Shared health facility
-An entity other
					 than a licensed or approved hospital facility, skilled nursing facility,
					 intermediate care facility, intermediate care facility for the mentally
					 retarded, rural health clinic, public clinic or Health Maintenance Organization
					 in which:
(i) Medical services, either
				  alone or together with support services, are provided at a single
				  location.
(ii) Services are
				  provided by three or more practitioners, two or more of whom are practicing
				  within different professions.
(iii)
				  Practitioners share any of the following: common waiting areas, examining
				  rooms, equipment, supporting staff or records.
(iv) At least one practitioner receives
				  payment on a fee for service basis.
(v) A provider receiving more than $30,000 in
				  payment from the MA Program during the 12-month period prior to the date of the
				  initial or renewal application of the shared health facility for registration
				  in the MA Program.
State Blind Pension recipient
-An
					 individual 21 years of age or older who by virtue of meeting the requirements
					 of Article V of the Public Welfare Code (62 P. S.
					 §§
											501-515) is eligible for pension
					 payments and payments made on his behalf for medical or other health care, with
					 the exception of inpatient hospital care and post-hospital care in the home
					 provided by a hospital. Payment for medical and health care is made solely from
					 Commonwealth funds since these individuals do not meet the criteria for Federal
					 funding of their medical care under Medicaid.
The provisions of this §
												1101.21 amended under sections
						201(2), 403(b), 443.1, 443.3, 443.4, 443.6, 448 and 454 of the Public Welfare
						Code (62 P. S. §§
													201(2),
						403(b), 443.1, 443.3, 443.4,
						443.6, 448 and 454).
This section cited in 55 Pa. Code §
												140.721 (relating to conditions of
						eligibility); 55 Pa. Code §
												1101.31 (relating to scope); 55
						Pa. Code §
												1101.63 (relating to payment in
						full); 55 Pa. Code §
												1187.11 (relating to scope of
						benefits for the categorically needy); 55 Pa. Code §
												1187.12 (relating to scope of
						benefits for the medically needy); and 55 Pa. Code §
												1187.152 (relating to additional
						reimbursement of nursing facility services related to exceptional
						DME).