Idaho Admin. Code r. 16.03.09.012 - DEFINITIONS: P THROUGH Z

Current through August 30, 2021

For the purposes of these rules, the following terms are used as defined below: (7-1-21)T

01. Participant. A person eligible for and enrolled in the Idaho Medical Assistance Program. (7-1-21)T
02. Patient. The person undergoing treatment or receiving services from a provider. (7-1-21)T
03. Pharmacist. A person who meets all the applicable requirements to practice as a licensed pharmacist according to the regulations in the state where the services are provided. (7-1-21)T
04. Physician. A person possessing a Doctor of Medicine degree or a Doctor of Osteopathy degree, and within the State or United States territory services are provided is either licensed to practice medicine or is a resident enrolled in a postgraduate medical training program. (7-1-21)T
05. Physician Assistant (PA). A person who meets all the applicable requirements to practice as a licensed physician assistant according to the regulations in the state where the services are provided. (7-1-21)T
06. Plan of Care. A written description of medical, remedial, or rehabilitative services to be provided to a participant, developed by or under the direction and written approval of a physician. Medications, services and treatments are identified specifically as to amount, type and duration of service. (7-1-21)T
07. Prepaid Ambulatory Health Plan (PAHP). As defined in 42 CFR 438.2, a PAHP is an entity that provides medical services to enrollees under contract with the Department on the basis of prepaid capitation payments, or other arrangements that do not use State Plan payment rates. The PAHP does not provide or arrange for, and is not responsible for the provision of any inpatient hospital or institutional services for its enrollees, and does not have a comprehensive risk contract. (7-1-21)T
08. Private Rate. Rate most frequently charged to private patients for a service or item. (7-1-21)T
09. Prosthetic Device. Replacement, corrective, or supportive devices prescribed by a physician or other licensed practitioner of the healing arts profession within the scope of their practice as defined by state law to: (7-1-21)T
a. Artificially replace a missing portion of the body; or (7-1-21)T
b. Prevent or correct physical deformities or malfunctions; or (7-1-21)T
c. Support a weak or deformed portion of the body. (7-1-21)T
d. Computerized communication devices are not included in this definition of a prosthetic device. (7-1-21)T
10. Provider. Any individual, partnership, association, corporation or organization, public or private, that furnishes medical goods or services in compliance with these rules and who has applied for and received a Medicaid provider number and who has entered into a written provider agreement with the Department in accordance with Section 205 of these rules. (7-1-21)T
11. Provider Agreement. A written agreement between the provider and the Department, entered into in accordance with Section 205 of these rules. (7-1-21)T
12. Provider Reimbursement Manual (PRM). A federal publication that specifies accounting treatments and standards for the Medicare program, CMS Publications 15-1 and 15-2, that are incorporated by reference in Section 004 of these rules. (7-1-21)T
13. Prudent Layperson. A person who possesses an average knowledge of health and medicine. (7-1-21)T
14. Psychologist, Licensed. A person licensed to practice psychology according to the regulations in the state where the services are provided. (7-1-21)T
15. Psychologist Extender. A person who practices psychology under the supervision of a licensed psychologist who meets the regulations in the state where the services are provided. (7-1-21)T
16. Public Provider. A public provider is one operated by a federal, state, county, city, or other local government agency or instrumentality. (7-1-21)T
17. Qualified Interpreter. A qualified interpreter meets the definition of qualified interpreter consistent with 28 CFR 35.104. (7-1-21)T
18. Quality Improvement Organization (QIO). An organization that performs utilization and quality control review of health care furnished to Medicare and Medicaid participants. A QIO is formerly known as a Peer Review Organization (PRO). (7-1-21)T
19. Related Entity. An organization with which the provider is associated or affiliated to a significant extent, or has control of, or is controlled by, that furnishes the services, facilities, or supplies for the provider. (7-1-21)T
20. Registered Nurse (RN). A person who meets all the applicable requirements and is licensed to practice as a Licensed Registered Nurse according to the regulations in the state where the services are provided. (7-1-21)T
21. Rural Health Clinic (RHC). An outpatient entity that meets the requirements of 42 USC Section 1395x(aa)(2). It is primarily engaged in furnishing physicians and other medical and health services in rural, federally-defined, medically underserved areas, or designated health professional shortage areas. (7-1-21)T
22. Rural Hospital-Based Nursing Facilities. Hospital-based nursing facilities not located within a metropolitan statistical area (MSA) as defined by the United States Bureau of Census. (7-1-21)T
23. Social Security Act. 42 USC 101 et seq., authorizing, in part, federal grants to the states for medical assistance to low-income persons who meet certain criteria. (7-1-21)T
24. State Plan. The contract between the state and federal government under 42 USC Section 1396a(a). (7-1-21)T
25. Supervision. Procedural guidance by a qualified person and initial direction and periodic inspection of the actual act, at the site of service delivery. (7-1-21)T
26. Title XVIII. Title XVIII of the Social Security Act, known as Medicare, for aged, blind, and disabled individuals administered by the federal government. (7-1-21)T
27. Title XIX. Title XIX of the Social Security Act, known as Medicaid, is a medical benefits program jointly financed by the federal and state governments and administered by the states. This program pays for medical assistance for certain individuals and families with low income and limited resources. (7-1-21)T
28. Title XXI. Title XXI of the Social Security Act, known as the State Children's Health Insurance Program (SCHIP). This is a program that primarily pays for medical assistance for low-income children. (7-1-21)T
29. Third Party. Includes a person, institution, corporation, public or private agency that is liable to pay all or part of the medical cost of injury, disease, or disability of a medical assistance participant. (7-1-21)T
30. Transportation. The physical movement of a participant to and from a medical appointment or service by the participant, another person, taxi or common carrier. (7-1-21)T

Notes

Idaho Admin. Code r. 16.03.09.012

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