The following words or terms, when used in this chapter, have
the following meanings unless the context clearly indicates otherwise.
(1) Access--The ability of an eligible client to obtain
health and health-related services, as determined by factors such
as: the availability of Texas Health Steps services; service acceptability
to the eligible child, pregnant woman, or both; the location of health
care facilities and other resources; transportation; hours of facility
operation; and length of time available to see the health care provider.
(2) Active Providers--Providers who have reported that
they are currently accepting referrals. Inactive providers are those
who have reported that they are not accepting referrals or have been
placed on inactive status by the department due the department's inability
to make contact with them.
(3) Applicant--An agency, organization, or individual
who submits an application to the department for approval as a provider
of Case Management for Children and Pregnant Women services.
(4) Application process--Submission of an application
to provide Case Management for Children and Pregnant Women services,
and the department's ensuing review and disposition of the application.
(5) Case manager--An individual qualified under §27.21
of this title (relating to Case Manager Qualifications) who provides
Case Management for Children and Pregnant Women services, either as
an independent provider, or as an employee or contractor of a case
(6) Case Management for Children and Pregnant Women
services--In reference to the federal regulation (42 C.F.R. §440.169)
definition of case management, those services that assist eligible
clients in gaining access to necessary medical, social, educational,
and other services related to their health condition/health risk or
(7) Children with a health condition/health risk--Children
birth through age 20 who have or are at risk for a medical condition,
illness, injury, or disability that results in limitation of function,
activities, or social roles in comparison with healthy peers of the
same age in the general areas of physical, cognitive, emotional, or
social growth and development.
(8) Client--An individual who is eligible for Medicaid
and receives services described under this chapter, or the client's
parent or legal guardian acting on the client's behalf.
(9) Client choice--Clients are given the freedom to
choose a provider, to the extent possible, from among three providers.
(10) Family--A basic unit in society having at its
nucleus: one or more adults living together and cooperating in the
care and rearing of their biological or adopted children; or a person
or persons acting as an individual's family, foster family, or identifiable
(11) Health and health-related services--Services which
are provided to meet the comprehensive (preventive, primary, tertiary,
and specialty) health needs of the eligible client, including, but
not limited to, medical and dental checkups, immunizations, acute
care visits, pediatric specialty consultations, physical therapy,
occupational therapy, audiology, speech language services, mental
health professional services, pharmaceuticals, medical supplies, prenatal
care, family planning, adolescent preventive health, durable medical
equipment, nutritional supplements, prosthetics, eyeglasses, and hearing
(12) High-risk condition--Applies to women who are
pregnant and have a medical and/or psychosocial condition(s) that
places them and their fetuses at a greater than average risk for complications,
either during pregnancy, delivery, or following birth.
(13) Medicaid--Medical assistance program implemented
by the State of Texas under the provisions of Title XIX of the Social
Security Act, as amended, at 42 U.S.C., §1396, et seq.
(14) Prior authorization--The department's approval
of a provider's request for permission to perform a comprehensive
visit and follow-up contacts with a client, based on the department's
receipt and review of documentation supporting the client's eligibility
for services under this chapter. Prior authorization is a condition
of reimbursement, not a guarantee of payment.
(15) Provider--An agency or individual approved by
the department to provide Case Management for Children and Pregnant
Women services and enrolled as a Medicaid provider.
(16) Quality Assurance Review--A review of a provider's
client records, internal quality assurance policy, case manager's
licensure, outreach materials, and their compliance with the department's
rules and policies.
(17) State--The State of Texas.
(18) TMPPM--Texas Medicaid Provider Procedures Manual.
(19) Utilization Review--A review of claims data in
which trends have been identified that could indicate potential concerns
with the quality of case management services.