Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 365 - KIDNEY HEALTH CARE › Section 365.2 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms when used in this subchapter
				  have the following meanings, unless the context clearly indicates
				  otherwise.
(1) Access surgery--The
				surgical procedure which creates or maintains the access site necessary to
				perform dialysis.
(2) Action--A
				suspension, modification, denial, or termination of program eligibility,
				benefits, or participation.
(3)
				Administrative review--A process that allows applicants, clients, or providers
				the opportunity to request an informal review of any intended program action
				that would suspend, modify, deny, or terminate their eligibility, benefits or
				participation in the program.
(4)
				Allowable amount--The maximum amount that the program will pay or reimburse for
				a covered benefit or service.
(5)
				Applicant--A person who has submitted an application for program benefits and
				has not received a final determination of eligibility.
(6) Authorized entity--Any individual or
				organization approved by the program to submit applications for benefits or
				travel verification reports on behalf of an applicant or client.
(7) Claim--A request for payment or
				reimbursement of services.
(8)
				Client--A person who has applied for program services and who meets all program
				eligibility requirements and is determined to be eligible for program
				services.
(9) CMS--The Centers for
				Medicare and Medicaid Services.
(10) Co-insurance--A cost-sharing arrangement
				in which a covered person is responsible for paying a specified percentage of
				the charge for a covered service or product.
(11) Commissioner--The commissioner of the
				Department of State Health Services.
(12) Co-pay/Co-payment--A cost-sharing
				arrangement in which a covered person is responsible for paying a specified or
				fixed charge for a covered service or product.
(13) CRNA--Certified registered nurse
				anesthetist.
(14) Date of service
				(DOS)--The date a service is rendered.
(15) Denial--An action by the program that
				disallows program eligibility, benefits, or provider enrollment.
(16) Department--The Department of State
				Health Services.
(17) Effective
				date--The date a program client or enrolled provider is approved to receive
				program benefits or reimbursements.
(18) End-Stage Renal Disease (ESRD)--The
				final stage of renal failure that requires dialysis or kidney transplant to
				reduce uremic symptoms and prevent the death of the patient.
(19) Enrolled provider--Any individual or
				entity who has completed all the requirements located in the Texas Health and
				Human Services Commission rule at 1 TAC §
									392.605,
				Kidney Health Care Provider Requirements and Effective Dates, and is deemed
				enrolled by the program to furnish covered services to program clients
				including:
(A) outpatient dialysis
				facilities;
(B) out-of-state
				outpatient dialysis facilities;
(C)
				hospitals and ambulatory surgical centers (ASCs) located in Texas and operating
				in compliance with applicable law;
(D) out-of-state hospitals and
				ASCs;
(E) military or Veterans
				Administration hospitals located in Texas which have a renal unit;
(F) pharmacies approved as Texas Medicaid
				providers and licensed to operate within the United States and its territories,
				including mail order pharmacies;
(G) physicians and certified registered nurse
				anesthetists (CRNAs) licensed in Texas;
(H) out-of-state physicians and CRNAs;
				and
(I) Medicare Prescription Drug
				Plan (PDP) providers.