The following words and terms, when used in this chapter, shall
have the following meanings, unless the context clearly indicates
otherwise.
(1) Advanced practice registered nurse--A registered
nurse authorized by the Texas Board of Nursing to practice as an advanced
practice registered nurse. The term includes a nurse practitioner,
nurse-midwife, nurse anesthetist, and clinical nurse specialist.
(2) Ambulance service supplier--A person, firm, or
institution approved for and participating in Medicare as an air,
ground, or specialized ambulance service supplier or provider.
(3) Ambulatory surgical center--A distinct health care
entity that operates exclusively for the purpose of providing certain
surgical services to patients not requiring overnight inpatient hospital
services. The center must meet the conditions for participation described
in §354.1211 of this subchapter (relating to Conditions for Participation)
and other applicable state and federal requirements.
(4) Approved laboratory--A laboratory that is independent
of a hospital or physician's office and that has been approved for
and is participating in Medicare and only for the procedures certified
to that laboratory under Medicare.
(5) Billing agent--A business agent as described in
42 CFR 447.10(f).
(6) Claim--A request for payment for authorized benefits
on the applicable approved form meeting the established itemization
requirements.
(7) Day--With respect to inpatient hospital services,
the time period of a day is counted for:
(A) hospital bed occupancy each midnight while under
registration in a hospital as an inpatient;
(B) each hospital bed occupancy where admission and
discharge occur on the same calendar day while under registration
in a hospital as an inpatient.
(8) Doctor--Doctor of chiropractic (chiropractor),
doctor of optometry (optometrist), doctor of podiatry (podiatrist),
or doctor of dentistry (doctor of dental surgery (DDS), doctor of
medical dentistry (DMD), and doctor of dental medicine (DDM)).
(9) Doctor of chiropractic, doctor of optometry, doctor
of podiatry, and doctor of dentistry (DDS, DMD, or DDM)--A licensed
doctor legally authorized to practice his specialty at the time and
place the service is provided.
(10) Eligible provider--An institution, facility, agency,
person, partnership, corporation, or association approved for participation
in the Texas Medicaid program in accordance with terms of this chapter.
"Eligible provider" also includes any person, firm, or institution
approved for and participating in Part B Medicare as a supplier or
provider of medical services or supplies, who is not otherwise designated
as an eligible Title XIX provider, and who meets the requirements
stipulated in this definition, except that such eligible provider
shall be an eligible Title XIX provider only for Part B Medicare services
or supplies and for the Title XIX payment of the deductible and coinsurance
liabilities.
(11) Eyeglasses--Eyewear dispensed and delivered that
is medically necessary and prescribed by a doctor of optometry or
physician, is professionally adjudged to be necessary and appropriate
for the lens, age, and sex of the eligible recipient, and significantly
improves visual acuity or impedes progression of visual problems.
The term "eyeglasses" does not include artificial eyes or any item
of eyewear for which benefits are not provided in the rules of the
Texas Health and Human Services Commission (HHSC) regarding the Medicaid
eyeglass program.
(12) Eyeglass supplier--A person, firm, or institution
that has entered into a written agreement with HHSC or its designee
as an eyeglass supplier on a form approved by HHSC; provided that
the benefits shall be available for eyeglass services and supplies
dispensed by an eyeglass supplier only if the fitting, adjustment,
and repair of the eyewear involved is performed by a physician, doctor
of optometry, or an optician; and provided that an eyeglass supplier
is an eligible provider under this program. Such suppliers must accept
the benefits paid as stipulated by HHSC as payment in full for the
service and supplies involved, except as otherwise provided.
(13) Family planning agency--A facility or institution
that has been determined by HHSC or its designee to qualify as a family
planning agency under standards of participation established by HHSC,
including any amendment of such standards of participation authorized
by HHSC. Family planning agencies shall accept as payment in full
the amount paid in accordance with the benefits as stipulated by HHSC.
(14) Health insuring agency--An organization legally
operating within the state that pays for the cost of certain medical
services available under the Title XIX state plan to eligible recipients
in exchange for premiums paid by HHSC and which assumes an underwriting
risk.
(15) HHSC--The Texas Health and Human Services Commission
or its designee.
(16) Hospital--Any institution licensed as a hospital
by the appropriate licensing authority but which is not a mental institution,
a health resort, nursing home, rest home, or any other institution
primarily providing convalescent or custodial care or which is otherwise
excluded under this chapter.
(17) Illness--A bodily disorder, bodily injury, disease,
or mental disease.
(18) Inpatient--A person registered and assigned a
medical record number by a hospital for bed occupancy in that hospital.
(19) Institution for mental diseases (IMD)--As defined
in 25 TAC §419.453(17) (relating to Definitions).
(20) Medicaid program--The Texas Medical Assistance
Program, a joint federal and state program provided for in Chapter
32, Texas Human Resources Code, and subject to Title XIX of the Social
Security Act, 42 U.S.C. §1396 et seq.
(21) Mental disease or disorder--Any condition classified
as a neurosis, psychoneurosis, psychopathy, psychosis, or personality
disorder.
(22) National provider identifier--The identification
number required under §1128J(e) of the Social Security Act (42
U.S.C. §1320a-7k(e)).
(23) Nonmedical public institution--An institution
or facility that is either a unit of, or under the administrative
control of a state, federal, or local government and that is not approved
for participation in the Medicaid program.
(24) Out-of-state hospital--A hospital located outside
of the State of Texas that participates as a general or acute care
hospital or both under Medicare or Title XIX, or both. Examples of
institutions that are excluded are institutions primarily for mental
disease or pulmonary care, a health resort, a nursing home, a rest
home, or any other institution primarily providing convalescent or
custodial care or that is otherwise excluded under this chapter.
(25) Outpatient--A person registered by a hospital
for outpatient services but not as an inpatient.
(26) Physician--A doctor of medicine or doctor of osteopathy
(MD or DO) legally authorized to practice medicine or osteopathy at
the time and place the service is provided.
(27) Physical therapist--A graduate of a program of
physical therapy approved by the Commission on Accreditation in Physical
Therapy Education (or one of the previously recognized accreditation
bodies), and licensed by the state in which the services are performed.
(28) Physical therapist assistant--A person licensed
by the appropriate state licensure board as a physical therapist assistant
and who provides physical therapy under the direction of a licensed
physical therapist.
(29) Physical therapy--Restorative services prescribed
by a physician and provided to a recipient by a qualified physical
therapist. It includes any necessary supplies and equipment.
(30) Prescription--A signed written or electronic order
by a physician or other healthcare practitioner acting within the
scope of his or her licensure. This includes a verbal order subsequently
countersigned by the practitioner or verified by the pharmacist.
(31) Psychologist--A person who is licensed to practice
as a psychologist in the state in which the service is performed.
(32) Recipient month--A calendar month of continuous
eligibility for one individual under the Medicaid program. Each month
covers eligibility for only one eligible recipient. Multiple recipient
months may cover eligibility for one or more eligible recipients or
eligibility for the same individual if prior months are involved.
Additional months of recipient eligibility may occur due to:
(A) certification of eligibility for up to three months
prior to date of application;
(B) eligibility for those individuals who are certified
to be eligible recipients after a first of the month;
(C) eligibility certified retroactively;
(D) certification of four months post eligibility for
certain individuals in the non-Medicare related aid to families with
dependent children coverage group; or
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