South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:06 - Children's special health services › Chapter 44:06:01 - General operation › Section 44:06:01:00 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Care coordination services," services to
				promote the effective and efficient organization and utilization of resources
				to ensure access to necessary comprehensive services for children with chronic
				medical conditions and their families;
(2) "Chronic medical condition," condition
				has existed or is expected to exist for two years or more, requires evaluation,
				consultation and medical treatment, and is a coverable condition under the CSHS
				program as listed in §
									44:06:06:01;
(3) "Client," an individual who is determined
				by CSHS to be eligible for and receiving services;
(4) "Consultation," the medical examination
				and testing by a specialist needed to determine the cause of and possible
				treatment for a suspected or known chronic medical condition;
(5) "Copay," the obligation of the family or
				legal guardian for either partial or full payment of the medical cost after
				submission of the bill to a health insurance plan;
(6) "Cost share," a family's percentage of
				financial participation in the cost of CSHS authorized services determined by
				family size and income;
(7) "CSHS,"
				children's special health services;
(8) "Deductible," the specified amount that
				must be met in medical costs and paid by the family or policy holder before a
				health insurance plan will pay;
(9)
				"Department," the South Dakota Department of Health;
(10) "Diagnostic services," use of scientific
				medical methods to establish the cause and nature of a person's illness or
				chronic medical condition;
(11)
				"Financial assistance," determined amount paid to a provider by CSHS on a
				client's behalf;
(12) "Individual
				case review," the process whereby a team of individuals from the department
				reviews a request to consider an individual's medical eligibility or
				treatment;
(13) "Participating
				provider," a provider who has a current, signed participating provider
				agreement with CSHS;
(14) "Primary
				care physician," the physician to whom a family or individual goes for
				management of care for acute illness and ongoing health needs;
(15) "Secretary," the South Dakota secretary
				of health or the secretary's designee;
(16) "Third-party resource," a public or
				private agency or entity which is or may be liable to pay all or part of the
				medical costs of an applicant or client, including private insurance, Civilian
				Health and Medical Program Uniformed Services, Medicaid, Medicare, Indian
				Health Services, and other sources of funds available to the applicant or
				client for medical care;
(17)
				"Treatment," medical or surgical intervention, or both, to alleviate a chronic
				medical condition; and
(18) "Usual
				and customary charge," the individual provider's normal charge to the general
				public for a specific service on the date the service was provided.
General Authority:
SDCL
					 34-1-21.
Law Implemented:
SDCL
					 34-1-21.