| (E) appropriately identified error adjustments.
(33) Respiratory care practitioner--A person certified
to practice respiratory care as defined in the Occupations Code, Chapter
604, relating to Respiratory Care Practitioners.
(34) Semiprivate room--A two-bed, three-bed, or four-bed
accommodation.
(35) State fiscal year--The 12-month period beginning
September 1 and ending August 31.
(36) State plan--The plan for administration of the
Medicaid program which is approved by the secretary of health and
human services in accordance with the provisions of Title XIX of the
Social Security Act, as amended.
(37) Substitute dentist--A doctor of dentistry (DDS,
DMD, or DDM) who provides services in place of another dentist of
the same license type under a billing arrangement. These arrangements
must comply with Medicaid policy, billing, reporting, and documentation
requirements.
(38) Therapeutic optometrist--A person certified by
the Texas Optometry Board to practice therapeutic optometry in accordance
with the Texas Optometry Act. References in this chapter to optometrists
include therapeutic optometrists.
(39) Third-party billing vendor--A vendor that submits
claims to HHSC, or its designee, for reimbursement on behalf of a
provider of medical services under the Medicaid program.
(40) Third-party liability--The resources that an eligible
recipient may have which serve as a source of payment for services
provided under the Medicaid program.
(41) Title XIX hospital--A hospital that is participating
as a hospital under Medicare, that has in effect a utilization review
plan approved by HHSC applicable to all eligible recipients to whom
it provides services or supplies, and has been designated by HHSC
as a Title XIX hospital or a hospital not meeting all of the requirements
listed in this definition but which provides services or supplies
for which benefits are provided under Medicare, the Social Security
Act, §1814(d), or would have been provided under such section
had the recipients to whom the services or supplies are provided been
eligible for and enrolled under Part A of Medicare, to the extent
of such services and supplies only, and then only if such hospital
has been designated by HHSC as a Title XIX emergency care only hospital,
or has been approved by HHSC to provide emergency hospital services
and agrees that the reasonable cost of such services or supplies,
as defined in the Social Security Act, §1902(a)(13), will be
such hospital's total charge for such services and supplies.
(42) Title XIX spell of illness--With respect to inpatient
hospital services, spell of illness is a continuous period of hospital
confinement. Successive periods of hospital confinement are considered
to be continuous unless the last date of discharge and the date of
readmission are separated by at least 60 consecutive days.
(43) Utilization review--The methods and procedures
related to the review of utilization of covered care and services
with respect to medical necessity and to safeguard against inappropriate
utilization of care and services.
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| Source Note: The provisions of this §354.1121 adopted to be effective May 30, 1977, 2 TexReg 1929; amended to be effective February 7, 1984, 9 TexReg 490; amended to be effective October 8, 1984, 9 TexReg 4975; amended to be effective September 3, 1985, 10 TexReg 3178; amended to be effective September 1, 1988, 13 TexReg 3829; amended to be effective February 19, 1990, 15 TexReg 658; amended to be effective January 23, 1991, 16 TexReg 124; amended to be effective October 1, 1991, 16 TexReg 5076; amended to be effective March 1, 1992, 17 TexReg 694; amended to be effective May 1, 1993, 18 TexReg 2307; transferred effective September 1, 1993, aspublished in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective September 12, 2004, 29 TexReg 8795; amended to be effective July 1, 2011, 36 TexReg 3705; amended to be effective January 8, 2013, 38 TexReg 19; amended to be effective November 25, 2015, 40 TexReg 8200; amended to be effective December 31, 2017, 42 TexReg 7381 |
