The following words and terms, when used in this chapter, shall have the following meanings unless the context clearly indicates otherwise. (1) Action--A denial, termination, suspension, or reduction of Medicaid-covered services; a denial of a prior authorization request for covered services affecting a recipient; the failure of the department to act upon a recipient request for Medicaid covered services within a reasonable time; or a lock-in. This term does not include reaching the date on which a time limited prior authorized service ends. This term does not include a provider action for which the recipient may be held financially liable by the provider. (2) Administrative Appeal--A request for review of, not a hearing on, claims denied by the claims administrator or claims processing entity for technical and non-medical reasons. (3) Day--A calendar day. (4) Commission--Health and Human Services Commission (5) Designee--The Commission's contractor who administers the claims processing for the Medicaid program. (6) Final decision--A decision that is reached by the Health and Human Services Commission staff and associated with an administrative, medical, or utilization review appeal or fair hearing. (7) Lock-in--An action taken by the Commission to restrict the recipient's choice of providers. (8) Managed care organization (MCO)--A managed care organization under contract with the Commission to provide services to Medicaid recipients. (9) Medical Appeal--A request for review of, not a hearing on, claims denied by the claims processing entity for medical necessity. (10) Prior authorized services--Services that are reimbursable only when authorization or approval is obtained before services are rendered. Prior authorized services may be limited in duration, scope, and amount. Services provided beyond those authorized are not reimbursable. If a prior authorization is limited in duration, scope or amount, a separate request and approval must be obtained for each prior authorized service. (11) Provider action--A denial or reduction of a provider claim for payment for services rendered to a Medicaid recipient. (12) Utilization Review Appeal--A request for review of, not a hearing on, a determination made by the HHSC Utilization Review department to the Medical Appeals area within HHSC. The authority related to this type of appeal may be found in 1 TAC §371.208. |
| Source Note: The provisions of this §354.2201 adopted to be effective May 29, 1997, 22 TexReg 4369; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4562; amended to be effective December 25, 2003, 28 TexReg 11251 |
