Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 27 - CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN › Subchapter A - GENERAL PROVISIONS › Section 27.3 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words or terms, when used in this chapter,
					 have the following meanings unless the context clearly indicates
					 otherwise.
(1) Access--The ability of
				  an eligible client to obtain health and health-related services, as determined
				  by factors such as: the availability of Texas Health Steps services; service
				  acceptability to the eligible child, pregnant woman, or both; the location of
				  health care facilities and other resources; transportation; hours of facility
				  operation; and length of time available to see the health care
				  provider.
(2) Active
				  Providers--Providers who have reported that they are currently accepting
				  referrals. Inactive providers are those who have reported that they are not
				  accepting referrals or have been placed on inactive status by the department
				  due the department's inability to make contact with them.
(3) Applicant--An agency, organization, or
				  individual who submits an application to the department for approval as a
				  provider of Case Management for Children and Pregnant Women services.
(4) Application process--Submission of an
				  application to provide Case Management for Children and Pregnant Women
				  services, and the department's ensuing review and disposition of the
				  application.
(5) Case manager--An
				  individual qualified under §
										27.21
				  of this title (relating to Case Manager Qualifications) who provides Case
				  Management for Children and Pregnant Women services, either as an independent
				  provider, or as an employee or contractor of a case management
				  provider.
(6) Case Management for
				  Children and Pregnant Women services--In reference to the federal regulation
				  (42 C.F.R.
				  §440.169) definition of case management,
				  those services that assist eligible clients in gaining access to necessary
				  medical, social, educational, and other services related to their health
				  condition/health risk or high-risk condition.
(7) Children with a health condition/health
				  risk--Children birth through age 20 who have or are at risk for a medical
				  condition, illness, injury, or disability that results in limitation of
				  function, activities, or social roles in comparison with healthy peers of the
				  same age in the general areas of physical, cognitive, emotional, or social
				  growth and development.
(8)
				  Client--An individual who is eligible for Medicaid and receives services
				  described under this chapter, or the client's parent or legal guardian acting
				  on the client's behalf.
(9) Client
				  choice--Clients are given the freedom to choose a provider, to the extent
				  possible, from among three providers.
(10) Family--A basic unit in society having
				  at its nucleus: one or more adults living together and cooperating in the care
				  and rearing of their biological or adopted children; or a person or persons
				  acting as an individual's family, foster family, or identifiable support
				  person(s).
(11) Health and
				  health-related services--Services which are provided to meet the comprehensive
				  (preventive, primary, tertiary, and specialty) health needs of the eligible
				  client, including, but not limited to, medical and dental checkups,
				  immunizations, acute care visits, pediatric specialty consultations, physical
				  therapy, occupational therapy, audiology, speech language services, mental
				  health professional services, pharmaceuticals, medical supplies, prenatal care,
				  family planning, adolescent preventive health, durable medical equipment,
				  nutritional supplements, prosthetics, eyeglasses, and hearing aids.
(12) High-risk condition--Applies to women
				  who are pregnant and have a medical and/or psychosocial condition(s) that
				  places them and their fetuses at a greater than average risk for complications,
				  either during pregnancy, delivery, or following birth.
(13) Medicaid--Medical assistance program
				  implemented by the State of Texas under the provisions of Title XIX of the
				  Social Security Act, as amended, at
				  42 U.S.C.,
				  §1396,
et
				  seq.
(14) Prior
				  authorization--The department's approval of a provider's request for permission
				  to perform a comprehensive visit and follow-up contacts with a client, based on
				  the department's receipt and review of documentation supporting the client's
				  eligibility for services under this chapter. Prior authorization is a condition
				  of reimbursement, not a guarantee of payment.
(15) Provider--An agency or individual
				  approved by the department to provide Case Management for Children and Pregnant
				  Women services and enrolled as a Medicaid provider.
(16) Quality Assurance Review--A review of a
				  provider's client records, internal quality assurance policy, case manager's
				  licensure, outreach materials, and their compliance with the department's rules
				  and policies.
(17) State--The State
				  of Texas.
(18) TMPPM--Texas
				  Medicaid Provider Procedures Manual.
(19) Utilization Review--A review of claims
				  data in which trends have been identified that could indicate potential
				  concerns with the quality of case management services.