Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XIII - Client Medical Management Programs › Section 12VAC30-130-800 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms when used in this part shall
					 have the following meanings unless the context clearly indicates
					 otherwise:
"Abuse" or "abusive activities" means practices by
					 individuals or providers that are inconsistent with sound fiscal or medical
					 practices and result in unnecessary costs to the Virginia Medicaid
					 program.
"Card-sharing" means
(i) the intentional sharing of an individual's eligibility
					 card for use by someone other than the individual for whom it was issued or
					 (ii) unauthorized use of an individual's eligibility card by one or more
					 persons other than the individual for whom it was issued due to the failure of
					 the individual to safeguard the card.
"Client Medical Management Program for individuals" or "CMM
					 Program for individuals" means the individuals' utilization control program
					 designed to prevent abuse and promote improved and cost efficient medical
					 management of essential health care for noninstitutionalized individuals
					 through restriction to one primary care provider or one pharmacy, or any
					 combination of these designated providers.
"Client Medical Management Program for providers" or "CMM
					 Program for providers" means the providers' utilization control program
					 designed to complement the individual abuse and utilization control program in
					 promoting improved and cost efficient medical management of essential health
					 care.
"Controlled substance" means a substance that has a
					 potential for abuse because physical and psychic dependence and tolerance may
					 develop upon repeated administration and that is classified as a Schedules I
					 through V drug.
"Covering provider" means a provider designated by the
					 primary provider to render health care services in the temporary absence of the
					 primary provider.
"DMAS" or "the department" means the Department of Medical
					 Assistance Services.
"Dental services" means covered dental services available
					 to Medicaid or FAMIS eligible children as well as the limited, emergency
					 services available to Medicaid eligible adults.
"Designated physician or pharmacy" means the provider who
					 agrees to be the designated physician or pharmacy from whom the restricted
					 individual must first attempt to seek medical or pharmaceutical services. Other
					 providers may be established as designated physician or pharmacy providers with
					 the approval of DMAS.
"Diagnosis" means
(i) the process of determining by examination the nature
					 and circumstances of a diseased condition or injury and (ii) the decision
					 reached from such examination.
"Diagnostic category" means the broad classification of
					 diseases and injuries found in the International Classification of Diseases
					 (ICD), which is commonly used by providers in billing for medical
					 services.
"Drug" means a substance or medication intended for use in
					 the diagnosis, cure, mitigation, treatment or prevention of disease as defined
					 by the Virginia Drug Control Act (§ 54.1-3400 et seq. of the Code of
					 Virginia).
"Duplicative medical care" means two or more practitioners
					 are concurrently treating the same or similar medical problems or conditions
					 falling into the same diagnostic category, but excluding confirmation for
					 diagnosis, evaluation, or assessment.
"Duplicative medications" means more than one prescription
					 of the same drug or more than one drug in the same therapeutic class.
"Education" means providing individuals with information
					 regarding DMAS' identification of inappropriate utilization and what is
					 appropriate access to Medicaid covered services according to the policies and
					 procedures of the CMM Program for individuals and the CMM Program for
					 providers. Education shall not include providing a professional opinion
					 regarding a individual's medical or mental health.
"Eligibility card" means the document issued to each
					 Medicaid individual listing the name and Medicaid number, either the
					 identification or billing number, of the eligible individual, which may be in
					 the form of a plastic card magnetically encoded, allowing electronic access to
					 inquiries for eligibility status.
"Emergency hospital services" means those hospital services
					 that are necessary to treat a medical emergency. Hospital treatment of a
					 medical emergency necessitates the use of the most accessible hospital
					 available that is equipped to furnish the required services.
"EPSDT" means the Early and Periodic Screening, Diagnosis,
					 and Treatment Program that is federally mandated for eligible individuals
					 younger than 21 years of age.
"Essential medical services" means quality medical
					 services, including but not limited to preventive care, emergency services,
					 maternity care, hospital and physician services, and prescription drug services
					 as set out in the State Plan for Medical Assistance.
"Excessive medical care" means obtaining greater than
					 necessary services such that health risks to the individual or unnecessary
					 costs to the Virginia Medicaid Program may ensue from the accumulation of
					 services or obtaining duplicative services.
"Excessive medications" means obtaining medication in
					 greater than generally acceptable maximum therapeutic dosage regimens or
					 obtaining duplicative medication from one or more practitioners.
"FAMIS" means the Family Access to Medical Insurance
					 Security program as created by Title XXI of the Social Security Act.
"Fraud" means an intentional deception or misrepresentation
					 made by a person with the knowledge that the deception could result in some
					 unauthorized benefit to himself or some other person. It includes any act that
					 constitutes fraud under applicable federal or state laws.
"Health care" means any covered service, including
					 equipment or supplies provided by any person, organization, or entity that
					 participates in the Virginia Medical Assistance Program.
"Home and community-based services" means a range of
					 community services approved by the Centers for Medicare and Medicaid Services
					 (CMS) pursuant to § 1915(c) of the Social Security Act to be offered to
					 individuals as an alternative to institutionalization.
"Hospice services" means services, pursuant to §
					 1905(o) of the Act, that are reasonable and necessary for the palliation or
					 management of a terminal illness if the terminal illness runs its normal
					 course.
"Immunization" means the creation of immunity against a
					 particular disease using a vaccination.
"Individual" means the recipient of Medicaid-covered
					 services that are provided under the authority of Titles XIX and XXI of the
					 Social Security Act.
"Java-Server Utilization Review System" or "JSURS" means a
					 computer subsystem of the Virginia Medicaid Management Information System
					 (VAMMIS) that collects claims data and computes statistical profiles of
					 individual and provider activity and compares such profiles with the
					 appropriate peer group.
"Managed care organization" or "MCO" means an entity that
					 meets the participation and solvency criteria defined in 42 CFR Part 438 and
					 has an executed agreement with the department to provide services covered under
					 (i) the Medallion II programs, pursuant to
					 12VAC30-120-360 et seq., or any
					 successor programs and (ii) the FAMIS programs, pursuant to 12VAC30-141, or any
					 successor programs.
"Medical emergency" means the sudden onset of a medical
					 condition manifesting itself by acute symptoms of sufficient severity,
					 including severe pain, that in the absence of immediate medical attention could
					 reasonably be expected to result in (i) placing the individual's health in
					 serious jeopardy, (ii) serious impairment of the individual's bodily functions,
					 or (iii) serious dysfunction of the individual's bodily organs or parts.
"Medically necessary" means services that are reasonable
					 and necessary for the diagnosis or treatment of an illness, condition, or
					 injury, or to improve the function of a disability, consistent with community
					 standards of medical practice and in accordance with Medicaid or FAMIS
					 policies.
"Noncompliance" means failing to follow Client Medical
					 Management Program policies and procedures, or a pattern of utilization that is
					 inconsistent with sound fiscal or medical practices. Noncompliance includes,
					 but is not limited to, failure to follow a recommended treatment plan or drug
					 regimen; failure to disclose to a provider any treatment or services provided
					 by another provider; or requests for medical services or medications that are
					 not medically necessary.
"Pattern" means a combination of qualities, acts, or
					 tendencies that result in duplication or frequent occurrence.
"Practitioner" means a health care provider licensed,
					 registered, or otherwise permitted by law to distribute, dispense, prescribe,
					 and administer drugs or otherwise treat medical conditions.
"Primary care provider" or "PCP" means a physician or nurse
					 practitioner practicing in accordance with state law who is responsible for
					 supervising, coordinating, and providing initial and primary medical care to
					 patients; for initiating written referrals for specialist care; and for
					 maintaining the continuity of patient care.
"Provider" means a person, organization, or institution
					 with a current, valid license or certification, as applicable, and
					 participation agreement with DMAS who or that will (i) render service to
					 Medicaid individuals who are eligible for covered services, (ii) submit a claim
					 or claims for the rendered services, and (iii) accept as payment in full the
					 amount paid by the Virginia Medicaid or FAMIS program.
"Psychotropic drugs" means drugs that alter the mental
					 activity, behavior, or perception. Examples of such drugs include morphine,
					 barbiturates, hypnotics, antianxiety agents, antidepressants, and
					 antipsychotics.
"Renal dialysis services" means services that aid the
					 process of diffusing blood across a semi-permeable membrane to remove
					 substances that a normal kidney would eliminate, including poisons, drugs,
					 urea, uric acid, and creatinine. Renal dialysis services help to restore
					 electrolytes and correct acid-base imbalances.
"Restrict" or "restriction" means an administrative action
					 imposed on an individual that limits access to specific types of health care
					 services through a designated primary provider or an administrative action
					 imposed on a provider to prohibit participation as a designated primary
					 provider, referral, or covering provider for restricted individuals.
"Social Security Act" or "the Act" means the statute,
					 enacted by the 74th Congress on August 14, 1935, and as amended, that provides
					 for the general welfare by establishing a system of federal old age benefits,
					 and by enabling the states to make more adequate provisions for aged persons,
					 blind persons, dependent children who have disabilities, maternal and child
					 welfare, public health, and the administration of their unemployment
					 compensation laws.
"State Plan for Medical Assistance" or "the Plan" means the
					 comprehensive written statement submitted by the department to the Centers for
					 Medicare and Medicaid Services (CMS) for approval describing the nature and
					 scope of the Virginia Medicaid program and giving assurance that it will be
					 administered in conformity with the requirements, standards, procedures, and
					 conditions for obtaining federal financial participation.
"Therapeutic class" means a group of drugs with similar
					 pharmacologic actions and uses.
"Under-use" or "under-utilization" means an occurrence
					 where there is evidence that an individual did not receive a service or
					 procedure whose benefits exceeded the risks.
"Utilization control" means the control of covered health
					 care services to assure the use of cost efficient, medically necessary or
					 appropriate services.
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396 et seq.