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TITLE 1ADMINISTRATION
PART 15TEXAS HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 353MEDICAID MANAGED CARE
SUBCHAPTER AGENERAL PROVISIONS
RULE §353.2Definitions

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...

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