The following words and terms, when used in this chapter, have
the following meanings, unless the context clearly indicates otherwise.
(1) Action--
(A) An action is defined as:
(i) the denial or limited authorization of a requested
Medicaid service, including the type or level of service;
(ii) the reduction, suspension, or termination of a
previously authorized service;
(iii) the failure to provide services in a timely manner;
(iv) the denial in whole or in part of payment for
a service; or
(v) the failure of a managed care organization (MCO)
to act within the timeframes set forth by the Texas Health and Human
Services Commission (HHSC) and state and federal law.
(B) "Action" does not include expiration of a time-limited
service.
(2) Acute care--Preventive care, primary care, and
other medical or behavioral health care provided by the provider or
under the direction of a provider for a condition having a relatively
short duration.
(3) Acute care hospital--A hospital that provides acute
care services.
(4) Adoption Assistance Program--The program administered
by DFPS in accordance with 40 TAC Chapter 700, Subchapter H (relating
to Adoption Assistance Program).
(5) Agreement or Contract--The formal, written, and
legally enforceable contract and amendments thereto between HHSC and
an MCO.
(6) Allowable revenue--All managed care revenue received
by the MCO pursuant to the contract during the contract period, including
retroactive adjustments made by HHSC. This would include any revenue
earned on Medicaid managed care funds such as investment income, earned
interest, or third party administrator earnings from services to delegated
networks.
(7) Appeal--The formal process by which a member or
his or her representative requests a review of the MCO's action.
(8) Applicant Provider--A physician or other health
care provider applying for expedited credentialing as defined in Texas
Government Code §533.0064.
(9) Behavioral health service--A covered service for
the treatment of mental, emotional, or substance use disorders.
(10) Capitated service--A benefit available to members
under the Texas Medicaid program for which an MCO is responsible for
payment.
(11) Capitation rate--A fixed predetermined fee paid
by HHSC to the MCO each month, in accordance with the contract, for
each enrolled member in exchange for which the MCO arranges for or
provides a defined set of covered services to the member, regardless
of the amount of covered services used by the enrolled member.
(12) CFR--Code of Federal Regulations.
(13) Children's Medicaid Dental Services--The dental
services provided through a dental MCO to a client birth through age
20.
(14) Clean claim--A claim submitted by a physician
or provider for health care services rendered to a member, with the
data necessary for the MCO or subcontracted claims processor to adjudicate
and accurately report the claim. A clean claim must meet all requirements
for accurate and complete data as further defined under the terms
of the contract executed between the MCO and HHSC.
(15) Client--Any Medicaid-eligible recipient.
(16) CMS--The Centers for Medicare & Medicaid Services,
which is the federal agency responsible for administering Medicare
and overseeing state administration of Medicaid.
(17) Complainant--A member, or a treating provider
or other individual designated to act on behalf of the member, who
files a complaint.
(18) Complaint--Any dissatisfaction expressed by a
complainant, orally or in writing, to the MCO about any matter related
to the MCO other than an action. Subjects for complaints may include:
(A) the quality of care of services provided;
(B) aspects of interpersonal relationships such as
rudeness of a provider or employee; and
(C) failure to respect the member's rights.
(19) Consumer Directed Services (CDS) option--A service
delivery option (also known as self-directed model with service budget)
in which an individual or legally authorized representative employs
and retains service providers and directs the delivery of certain
program services.
(20) Covered services--Unless a service or item is
specifically excluded under the terms of the state plan, a federal
waiver, a managed care services contract, or an amendment to any of
these, the phrase "covered services" means all health care, long term
services and supports, or dental services or items that the MCO must
arrange to provide and pay for on a member's behalf under the terms
of the contract executed between the MCO and HHSC, including:
(A) all services or items comprising "medical assistance"
as defined in §32.003 of the Human Resources Code; and
(B) all value-added services under such contract.
(21) Credentialing--The process through which an MCO
collects, assesses, and validates qualifications and other relevant
information pertaining to a Medicaid enrolled health care provider
to determine whether the provider may be contracted to deliver covered
services as part of the network of the managed care organization.
(22) Cultural competency--The ability of individuals
and systems to provide services effectively to people of various disabilities,
cultures, races, ethnic backgrounds, and religions in a manner that
recognizes, values, affirms, and respects the worth of the individuals
and protects and preserves their dignity.
(23) Day--A calendar day, unless specified otherwise.
(24) Default enrollment--The process established by
HHSC to assign a Medicaid managed care enrollee to an MCO when the
enrollee has not selected an MCO.
(25) Dental contractor--A dental MCO that is under
contract with HHSC for the delivery of dental services.
(26) Dental home--A provider who has contracted with
a dental MCO to serve as a dental home to a member and who is responsible
for providing routine preventive, diagnostic, urgent, therapeutic,
initial, and primary care to patients, maintaining the continuity
of patient care, and initiating referral for care. Provider types
that can serve as dental homes are federally qualified health centers
and individuals who are general dentists or pediatric dentists.
(27) Dental managed care organization (dental MCO)--A
dental indemnity insurance provider or dental health maintenance organization
licensed or approved by the Texas Department of Insurance.
(28) Dental service--The routine preventive, diagnostic,
urgent, therapeutic, initial, and primary care provided to a member
and included within the scope of HHSC's agreement with a dental contractor.
For purposes of this chapter, "dental service" does not include dental
devices for craniofacial anomalies; treatment rendered in a hospital,
urgent care center, or ambulatory surgical center setting for craniofacial
anomalies; or emergency services provided in a hospital, urgent care
center, or ambulatory surgical center setting involving dental trauma.
These types of services are treated as health care services in this
chapter.
(29) DFPS--The Texas Department of Family and Protective
Services.
(30) Disability--A physical or mental impairment that
substantially limits one or more of an individual's major life activities,
such as caring for oneself, performing manual tasks, walking, seeing,
hearing, speaking, breathing, learning, socializing, or working.
(31) Disproportionate Share Hospital (DSH)--A hospital
that serves a higher than average number of Medicaid and other low-income
patients and receives additional reimbursement from the State.
(32) Dual eligible--A Medicaid recipient who is also
eligible for Medicare.
(33) Elective enrollment--Selection of a primary care
provider (PCP) and MCO by a client during the enrollment period established
by HHSC.
(34) Emergency behavioral health condition--Any condition,
without regard to the nature or cause of the condition, that in the
opinion of a prudent layperson possessing an average knowledge of
health and medicine:
(A) requires immediate intervention and/or medical
attention without which the client would present an immediate danger
to themselves or others; or
(B) renders the client incapable of controlling, knowing,
or understanding the consequences of his or her actions.
(35) Emergency medical condition--A medical condition
manifesting itself by acute symptoms of recent onset and sufficient
severity (including severe pain), such that a prudent layperson, who
possesses an average knowledge of health and medicine, could reasonably
expect the absence of immediate medical care to result in:
(A) placing the patient's health in serious jeopardy;
Cont'd... |