Kan. Admin. Regs. § 30-5-58 - Definitions
The following words and terms, when used in this article, shall have the following meanings, unless the context clearly indicates otherwise.
(a) "Accept medicare assignment"
means the provider will accept the medicare-allowed payment rate as payment in
full for services provided to a recipient.
(b) "Accrual basis accounting" means that
revenue of the provider is reported in the period in which it is earned,
regardless of when it is collected, and expenses are reported in the period in
which they are incurred, regardless of when they are paid.
(c) "Acquisition cost" means the allowable
reimbursement price for each covered drug, supply, or device as determined by
the secretary in accordance with federal regulations.
(d) "Admission" means entry into a hospital
for the purpose of receiving inpatient medical treatment.
(e) "Agency" means the department of social
and rehabilitation services.
(f)
"Ambulance" means a state-licensed vehicle equipped for emergency
transportation of injured or sick recipients to facilities where medical
services are rendered.
(g)
"Arm's-length transaction" means a transaction between unrelated parties.
(h) "Border cities" means those
communities outside of the state of Kansas but within a 50-mile range of the
state border.
(i) "Capitated
managed care" means a type of managed care plan that uses a risk-sharing
reimbursement method whereby providers receive fixed periodic payments for
health services rendered to plan members. Capitated fees shall be set by
contract with providers and shall be paid on a per person basis regardless of
the amount of services rendered or costs incurred.
(j) "Capitation reimbursement" means a
reimbursement methodology establishing payment rates, per program consumer or
eligible individual, for a designated group of services.
(k) "Case conference" means a scheduled,
face-to-face meeting involving two or more persons to discuss problems
associated with the treatment of the facility's patient or patients. Persons
involved in the case conference may include treatment staff, or other
department representatives of the client or clients.
(l) "Change of ownership" means a change that
involves the following:
(1) An arm's-length
transaction between unrelated parties; and
(2)
(A) The
dissolution or creation of a partnership when no member of the dissolved
partnership or the new partnership retains ownership interest from the previous
ownership affiliation;
(B) a
transfer of title and property to another party if the property is owned by a
sole proprietor;
(C) the change or
creation of a new lessee acting as a provider of pharmacy services; or
(D) a consolidation of two or more
corporations that creates a new corporate entity. The transfer of participating
provider corporate stock shall not in itself constitute a change of ownership.
A merger of one or more corporations with a participating provider corporation
surviving shall not constitute a change of ownership.
(m) "Common control" means that an
individual or organization has the power, directly or indirectly, to
significantly influence or direct the actions or policies of an organization or
facility.
(n) "Common ownership"
means that an entity holds a minimum of five percent ownership or equity in the
provider facility and in the company engaged in business with the provider
facility.
(o) "Comparable
outpatient service" means a service that is provided in a hospital and that is
comparable to a service provided in a physician's office or ambulatory surgical
center.
(p) "Concurrent care"
means services rendered simultaneously by two or more eligible providers.
(q) "Consultation" means an
evaluation that requires another examination by a provider of the same
profession, a study of records, and a discussion of the case with the physician
primarily responsible for the patient's care.
(r) "Contract loss" means the excess of
contract cost over contract income.
(s) "Cost and other accounting information"
means adequate data, including source documentation, that is accurate, current,
and in sufficient detail to accomplish the purposes for which it is intended.
Source documentation, including petty cash payout memoranda and original
invoices, shall be valid only if it originated at the time and near the place
of the transaction. In order to provide the required cost data, financial and
statistical records shall be maintained in a consistent manner. This
requirement shall not preclude a beneficial change in accounting procedures
when there is a compelling reason to effect a change of procedure.
(t) "Cost finding" means the process of
recasting the data derived from the accounts ordinarily kept by a provider to
ascertain costs of the various types of services rendered.
(u) "Cost outlier" means a general hospital
inpatient stay with an estimated cost that exceeds the cost outlier limit
established for the respective diagnosis-related group.
(v) "Cost outlier limit" means the maximum
cost of a general hospital inpatient stay established according to a
methodology specified by the secretary for each diagnosis-related group.
(w) "Cost-related reimbursement"
means reimbursement based on analysis and consideration of the historical
operating costs required to provide specified services.
(x) "Costs not related to patient care" means
costs that are not appropriate, necessary, or proper in developing and
maintaining the facility's operations and activities. These costs shall not be
allowed in computing reimbursable costs under cost-related reimbursement.
(y) "Costs related to patient
care" means all necessary and proper costs arising from arm's-length
transactions in accordance with generally accepted accounting principles that
are appropriate and helpful in developing and maintaining the operation of
patient care facilities and activities.
(z) "Covered service" means a medical service
for which reimbursement will be made by the medicaid/medikan program. Coverage
may be limited by the secretary through prior authorization requirements.
(aa) "Day outlier" means a general
hospital inpatient length of stay that exceeds the day outlier limit
established for the respective diagnosis-related group.
(bb) "Day outlier limit" means the maximum
general hospital inpatient length of stay established according to a
methodology specified by the secretary for each diagnosis-related group.
(cc) "Diagnosis-related group" or
"DRG" means the classification system that arranges medical diagnoses into
mutually exclusive groups.
(dd)
"Diagnosis-related group adjustment percent" or "DRG adjustment percent" means
a percentage assigned by the secretary to a diagnosis-related group for
purposes of computing reimbursement.
(ee) "Diagnosis-related group daily rate" or
"DRG daily rate" means the dollar amount assigned by the secretary to a
diagnosis-related group for purposes of computing reimbursement when a rate per
day is required.
(ff)
"Diagnosis-related group reimbursement system" or "DRG reimbursement system"
means a reimbursement system in the Kansas medicaid/medikan program for general
hospital inpatient services that uses diagnosis-related groups for determining
reimbursement on a prospective basis.
(gg) "Diagnosis-related group weight" or "DRG
weight" means the numeric value assigned to a diagnosis-related group for
purposes of computing reimbursement.
(hh) "Discharge" means release from a
hospital. A discharge shall occur when the consumer leaves the hospital or
dies. A transfer to another unit within a hospital, except to a swing bed, and
a transfer to another hospital shall not be a discharge.
(ii) "Discharging hospital" means, in
instances of the transfer of a consumer, the hospital that discharges the
consumer admitted from the last transferring hospital.
(jj) "Dispensing fee" means the reimbursement
rate assigned to each individual pharmacy provider for the provision of
pharmacy services involved in dispensing a prescription.
(kk) "Disproportionate share hospital" means
a hospital that has the following:
(1) Either
a low-income utilization rate exceeding 25 percent or a medicaid/medikan
hospital inpatient utilization rate of at least one standard deviation above
the mean medicaid/medikan inpatient utilization rate for hospitals within the
state borders of Kansas that are receiving medicaid/medikan payments; and
(2) at least two obstetricians
with staff privileges at the hospital who have agreed to provide obstetric
services to medicaid/medikan eligible individuals. In a hospital located in a
rural area, the obstetrician may be any physician with staff privileges at the
hospital who performs nonemergency obstetric procedures. The only exceptions to
this requirement shall be the following:
(A)
A hospital with inpatients who are predominantly under 18 years of age; or
(B) a hospital that did not offer
nonemergency obstetric services as of December 21, 1987.
(ll) "Drug, supply, or device"
means the following:
(1) Any article
recognized in the official United States pharmacopoeia, another similar
official compendium of the United States, an official national formulary, or
any supplement of any of these publications;
(2) any article intended for use in the
diagnosis, cure, mitigation, treatment, or prevention of disease in human
beings;
(3) any article intended
to affect the structure or any function of the bodies of human beings; and
(4) any article intended for use
as a component of any article specified in paragraphs (1), (2), or (3) above.
(mm) "Durable medical
equipment" or "DME" means equipment that meets these conditions:
(1) Withstands repeated use;
(2) is not generally useful to a person in
the absence of an illness or injury;
(3) is primarily and customarily used to
serve a medical purpose;
(4) is
appropriate for use in the home; and
(5) is rented or purchased as determined by
designees of the secretary.
(nn) "Election period" means the period of
time for the receipt of hospice care, beginning with the first day of hospice
care as provided in the election statement and continuing through any
subsequent days.
(oo) "Election
statement" means the revokable statement signed by a consumer that is filed
with a particular hospice and that consists of the following:
(1) Identification of the hospice selected to
provide care;
(2) acknowledgment
that the consumer has been given a full explanation of hospice care;
(3) acknowledgment by the consumer that other
medicaid services are waived;
(4)
the effective date of the election period; and
(5) the consumer's signature or the signature
of the consumer's legal representative.
(pp) "Emergency services" means those
services provided after the sudden onset of a medical condition manifesting
itself by acute symptoms of sufficient severity, including severe pain, such
that the absence of immediate medical attention could reasonably be expected to
result in any of the following:
(1) Serious
jeopardy to the patient's health;
(2) serious impairment to bodily functions;
or
(3) serious dysfunction of any
bodily organ or part.
(qq) "Estimated cost" means the cost of
general hospital inpatient services provided to a consumer, as computed using a
methodology set out in the Kansas medicaid state plan.
(rr) "Formulary" means a listing of drugs,
supplies, or devices.
(ss)
"Free-standing inpatient psychiatric facility" means an inpatient psychiatric
facility licensed to provide services only to the mentally ill.
(tt) "General hospital" means an
establishment that provides an organized medical staff of physicians, permanent
facilities that include inpatient beds, and medical services. The medical
services provided by the hospital shall include the following:
(1) Physician services;
(2) continuous registered professional
nursing services for 24 hours each day; and
(3) diagnosis and treatment for nonrelated
patients who have a variety of medical conditions.
(uu) "General hospital group" means the
category to which a general hospital is assigned for purposes of computing
reimbursement.
(vv) "General
hospital inpatient beds" means the number of beds reported by a general
hospital on the hospital and hospital health care complex cost report form,
excluding those beds designated as skilled nursing facility or intermediate
care facility beds. For hospitals not filing the hospital and hospital health
care complex cost report form, the number of beds shall be obtained from the
provider application for participation in the Kansas medicaid/medikan program
form.
(ww) "Generally accepted
accounting procedures" means generally accepted accounting principles, except
as otherwise specifically indicated by medicaid/medikan program policies and
regulations. These principles shall not supersede any specific regulation or
policy of the medicaid/medikan program.
(xx) "Group reimbursement rate" means the
dollar value assigned by the secretary to each general hospital group for a
diagnosis-related group weight of one.
(yy) "Health maintenance organization" means
an organization of providers of designated medical services that makes
available and provides these medical services to eligible enrolled individuals
for a fixed periodic payment determined in advance and that limits referral to
outside specialists.
(zz)
"Historical cost" means actual allowable costs incurred for a specified period
of time.
(aaa) "Hospice" means a
public agency, private organization, or a subdivision of either, that primarily
engages in providing care to terminally ill individuals, meets the medicare
conditions of participation for hospices, and has enrolled to provide hospice
services as provided in K.A.R. 30-5-59.
(bbb) "Hospital located in a rural area"
means a facility located in an area outside of a metropolitan statistical area
as defined in paragraph (sss).
(ccc) "Independent laboratory" means a
laboratory that performs laboratory tests ordered by a physician and that is in
a location other than the physician's office or a hospital.
(ddd) "Ineligible provider" means a provider
who is not enrolled in the medicaid/medikan program because of reasons set
forth in K.A.R. 30-5-60, or because of commission of civil or criminal fraud in
another state or another program.
(eee) "Interest expense" means the cost
incurred for the use of borrowed funds on a loan made for a purpose related to
patient care.
(fff) "Kan Be
Healthy program participant" means an individual under the age of 21 who is
eligible for medicaid, and who has undergone a Kan Be Healthy medical screening
in accordance with a specified screening schedule. The medical screening shall
be performed for the following purposes:
(1)
To ascertain physical and mental defects; and
(2) to provide treatment that corrects or
ameliorates defects and chronic conditions that are found.
(ggg) "Kan Be Healthy dental-only
participant" means an individual under the age of 21 who is eligible for
medicaid, and has undergone only a Kan Be Healthy dental screening in
accordance with a specified screening schedule. The dental screening shall be
performed for the following purposes:
(1) To
ascertain dental defects; and
(2)
to provide treatment that corrects or ameliorates dental defects and chronic
dental conditions that are found.
(hhh) "Kan Be Healthy vision-only
participant" means an individual under the age of 21 who is eligible for
medicaid, and who has undergone only a Kan Be Healthy vision screening in
accordance with a specified screening schedule. The vision screening shall be
performed for the following purposes:
(1)
Ascertain vision defects; and
(2)
provide treatment that corrects or ameliorates vision defects and chronic
vision conditions that are found.
(iii) "Length of stay as an inpatient in a
general hospital" means the number of days an individual remains for treatment
as an inpatient in a general hospital from and including the day of admission,
to and excluding the day of discharge.
(jjj) "Lock-in" means the restriction,
through limitation of the use of the medical identification card to designated
medical providers, of a consumer's access to medical services because of abuse.
(kkk) "Low-income utilization rate
for hospitals" means the rate that is defined in accordance with section 1923
of the social security act, codified at 42 U.S.C. 1396r-4, as amended by
section 1(a)(6) of the consolidated appropriations act, 2001
P.L.
106-554 , which enacted into law Section 701 of
H.R. 5661, the medicare, medicaid, and SCHIP benefits improvement and
protection act of 2000, effective December 21, 2000, which is adopted by
reference.
(lll) "Managed care"
means a system of managing and financing health care delivery to ensure that
services provided to managed care plan members are necessary, efficiently
provided, and appropriately priced.
(mmm) "Managerial capacity" means the
authority of an individual, including a general manager, business manager,
administrator or director, who performs the following functions:
(1) Exercises operational or managerial
control over the provider; or
(2)
directly or indirectly conducts the day-to-day operations of the provider.
(nnn) "Maternity
center" means a facility licensed as a maternity hospital that provides
delivery services for normal, uncomplicated pregnancies.
(ooo)
(1)
"Medical necessity" means that a health intervention is an otherwise covered
category of service, is not specifically excluded from coverage, and is
medically necessary, according to all of the following criteria:
(A) "Authority." The health intervention is
recommended by the treating physician and is determined to be necessary by the
secretary or the secretary's designee.
(B) "Purpose." The health intervention has
the purpose of treating a medical condition.
(C) "Scope." The health intervention provides
the most appropriate supply or level of service, considering potential benefits
and harms to the patient.
(D)
"Evidence." The health intervention is known to be effective in improving
health outcomes. For new interventions, effectiveness shall be determined by
scientific evidence as provided in paragraph (ooo)(3). For existing
interventions, effectiveness shall be determined as provided in paragraph
(ooo)(4).
(E) "Value." The health
intervention is cost-effective for this condition compared to alternative
interventions, including no intervention. "Cost-effective" shall not
necessarily be construed to mean lowest price. An intervention may be medically
indicated and yet not be a covered benefit or meet this regulation's definition
of medical necessity. Interventions that do not meet this regulation's
definition of medical necessity may be covered at the choice of the secretary
or the secretary's designee. An intervention shall be considered cost effective
if the benefits and harms relative to costs represent an economically efficient
use of resources for patients with this condition. In the application of this
criterion to an individual case, the characteristics of the individual patient
shall be determinative.
(2) The following definitions shall apply to
these terms only as they are used in this subsection (ooo);
(A) "Effective" means that the intervention
can be reasonably expected to produce the intended results and to have expected
benefits that outweigh potential harmful effects.
(B) "Health intervention" means an item or
service delivered or undertaken primarily to treat a medical condition or to
maintain or restore functional ability. For this regulation's definition of
medical necessity, a health intervention shall be determined not only by the
intervention itself, but also by the medical condition and patient indications
for which it is being applied.
(C)
"Health outcomes" means treatment results that affect health status as measured
by the length or quality of a person's life.
(D) "Medical condition" means a disease,
illness, injury, genetic or congenital defect, pregnancy, or a biological or
psychological condition that lies outside the range of normal, age-appropriate
human variation.
(E) "New
intervention" means an intervention that is not yet in widespread use for the
medical condition and patient indications under consideration.
(F) "Scientific evidence" means controlled
clinical trials that either directly or indirectly demonstrate the effect of
the intervention on health outcomes. However, if controlled clinical trials are
not available, observational studies that demonstrate a causal relationship
between the intervention and health outcomes may be used. Partially controlled
observational studies and uncontrolled clinical series may be considered to be
suggestive, but shall not by themselves be considered to demonstrate a causal
relationship unless the magnitude of the effect observed exceeds anything that
could be explained either by the natural history of the medical condition or
potential experimental biases.
(G)
"Secretary's designee" means a person or persons designated by the secretary to
assist in the medical necessity decision-making process.
(H) "Treat" means to prevent, diagnose,
detect, or palliate a medical condition.
(I) "Treating physician" means a physician
who has personally evaluated the patient.
(3) Each new intervention for which clinical
trials have not been conducted because of epidemiological reasons, including
rare or new diseases or orphan populations, shall be evaluated on the basis of
professional standards of care or expert opinion as described below in
paragraph (ooo)(4).
(4) The
scientific evidence for each existing intervention shall be considered first
and, to the greatest extent possible, shall be the basis for determinations of
medical necessity. If no scientific evidence is available, professional
standards of care shall be considered. If professional standards of care do not
exist, or are outdated or contradictory, decisions about existing interventions
shall be based on expert opinion. Coverage of existing interventions shall not
be denied solely on the basis that there is an absence of conclusive scientific
evidence. Existing interventions may be deemed to meet this regulation's
definition of medical necessity in the absence of scientific evidence if there
is a strong consensus of effectiveness and benefit expressed through up-to-date
and consistent professional standards of care or, in the absence of those
standards, convincing expert opinion.
(ppp) "Medical necessity in psychiatric
situations" means that there is medical documentation that indicates either of
the following:
(1) The person could be
harmful to himself or herself or others if not under psychiatric treatment; or
(2) the person is disoriented in
time, place, or person.
(qqq) "Medical supplies" means items that
meet these conditions:
(1) Are not generally
useful to a person in the absence of illness or injury;
(2) are prescribed by a physician; and
(3) are used in the home and
certain institutional settings.
(rrr) "Mental retardation" means any
significant limitation in present functioning that meets these requirements:
(1) Is manifested during the period of birth
to age 18;
(2) is characterized by
significantly subaverage intellectual functioning as reflected by a score of
two or more standard deviations below the mean, as measured by a generally
accepted, standardized, individual measure of general intellectual functioning;
and
(3) exists concurrently with
deficits in adaptive behavior, including related limitations in two or more of
the following areas: communication, self-care, home living, social skills,
community use, self-direction, health and safety, functional academics,
leisure, and work.
(sss) "Metropolitan statistical area" or
"MSA" means a geographic area designated as such by the United States executive
office of management and budget as set out in the 64 Fed. Reg. 202, pp.
56628-56644, October 20, 1999, and 65 Fed. Reg. 249, pp. 82228-82238, December
27, 2000 which are adopted by reference.
(ttt) "Necessary interest" means interest
expense incurred on a loan made to satisfy a financial need of the facility. A
loan that results in excess funds or investments shall not be considered
necessary.
(uuu) "Net cost" means
the cost of approved educational activities, less any reimbursements from the
following:
(1) Grants;
(2) tuition; and
(3) specific donations.
(vvv) "Non-covered services" means services
for which medicaid/medikan will not provide reimbursement, including services
that have been denied due to the lack of medical necessity.
(www) "Occupational therapy" means the
provision of treatment by an occupational therapist registered with the
American occupational therapy association. The treatment shall meet these
requirements:
(1) Be rehabilitative and
restorative in nature;
(2) be
provided following physical debilitation due to acute physical trauma or
physical illness; and
(3) be
prescribed by the attending physician.
(xxx) "Organization costs" means those costs
directly incidental to the creation of the corporation or other form of
business. These costs shall be considered intangible assets because they
represent expenditures for rights and privileges that have value to the
enterprise. Because the services inherent in organization extend over more than
one accounting period, the costs shall be amortized over a period of not less
than 60 months from the date of incorporation for the purposes of computing
reimbursable costs under a cost-related reimbursement system.
(yyy) "Orthotics and prosthetics" means
devices that meet these requirements:
(1) Are
reasonable and necessary for treatment of an illness or injury;
(2) are prescribed by a physician;
(3) are necessary to replace or improve
functioning of a body part; and
(4) are provided by a trained orthotist or
prosthetist.
(zzz)
"Other developmental disability" means a condition or illness that meets the
following criteria:
(1) Is manifested before
age 22;
(2) may reasonably be
expected to continue indefinitely;
(3) results in substantial limitations in any
three or more of the following areas of life functioning:
(A) Self-care;
(B) understanding and the use of language;
(C) learning and adapting;
(D) mobility;
(E) self-direction in setting goals and
undertaking activities to accomplish those goals;
(F) living independently; or
(G) economic self-sufficiency; and
(4) reflects the need for a
combination and sequence of special, interdisciplinary, or generic care,
treatment, or other services that are of extended or lifelong duration and are
individually planned and coordinated.
(aaaa) "Out-of-state provider" means any
provider that is physically located more than 50 miles beyond the border of
Kansas, except those providing services to children who are wards of the
secretary. The following shall be considered out-of-state providers if they are
physically located beyond the border of Kansas:
(1) Nursing facilities;
(2) intermediate care facilities;
(3) community mental health centers;
(4) partial hospitalization
service providers; and
(5) alcohol
and drug program providers.
(bbbb) "Outpatient treatment" means services
provided by the outpatient department of a hospital, a facility that is not
under the administration of a hospital, or a physician's office.
(cccc) "Over-the-counter" means any item
available for purchase without a prescription order.
(dddd) "Owner" means a sole proprietor,
member of a partnership, or a corporate stockholder with five percent or more
interest in the corporation. The term "owner" shall not include minor
stockholders in publicly held corporations.
(eeee) "Partial hospitalization program"
means an ambulatory treatment program that includes the major diagnostic,
medical, psychiatric, psychosocial, and daily living skills treatment
modalities, based upon a treatment plan.
(ffff) "Participating provider" means any
individual or entity that presently has an agreement with the agency to furnish
medicaid services.
(gggg)
"Pharmacy" means the premises, laboratory, area, or other place meeting these
conditions:
(1) Where drugs are offered for
sale, the profession of pharmacy is practiced, and prescriptions are compounded
and dispensed;
(2) that has
displayed upon it or within it the words "pharmacist," "pharmaceutical
chemist," "pharmacy," "apothecary," "drugstore," "druggist," "drugs," "drug
sundries," or any combinations of these words or words of similar import; and
(3) where the characteristic
symbols of pharmacy or the characteristic prescription sign "Rx" are exhibited.
The term "premises" as used in this subsection refers only to the portion of
any building or structure leased, used, or controlled by the registrant in the
conduct of the business registered by the board at the address for which the
registration was issued.
(hhhh) "Pharmacist" means any person duly
licensed or registered to practice pharmacy by the state board of pharmacy or
by the regulatory authority of the state in which the person is engaged in the
practice of pharmacy.
(iiii)
"Physical therapy" means treatment that meets these criteria:
(1) Is provided by a physical therapist
registered in the jurisdiction where the service is provided or by the Kansas
board of healing arts;
(2) is
rehabilitative and restorative in nature;
(3) is provided following physical
debilitation due to acute physical trauma or physical illness; and
(4) is prescribed by the attending physician.
(jjjj) "Physician
extender" means a person registered as a physician's assistant or licensed
advanced registered nurse practitioner in the jurisdiction where the service is
provided, and who is working under supervision as required by law or
administrative regulation.
(kkkk)
"Practitioner" means any person licensed to practice medicine and surgery,
dentistry, or podiatry, or any other person licensed, registered, or otherwise
authorized by law to administer, prescribe, and use prescription-only drugs in
the course of professional practice.
(llll) "Prescribed" means the issuance of a
prescription order by a practitioner.
(mmmm) "Prescription" means either of the
following:
(1) A prescription order; or
(2) a prescription medication.
(nnnn) "Prescription
medication" means any drug, supply, or device that is dispensed according to a
prescription order. If indicated by the context, the term "prescription
medication" may include the label and container of the drug, supply, or device.
(oooo) "Prescription-only" means
an item available for purchase only with a prescription order.
(pppp) "Primary care case management" or
"PCCM" means a type of managed care whereby a beneficiary is assigned a primary
care case manager who manages costs and quality of services by providing case
assessment, primary services, treatment planning, referral, and follow-up in
order to ensure comprehensive and continuous service and coordinated
reimbursement.
(qqqq) "Primary
diagnosis" means the most significant diagnosis related to the services
rendered.
(rrrr) "Prior
authorization" means the approval of a request to provide a specific service
before the provision of the service.
(ssss) "Program" means the Kansas
medicaid/medikan program.
(tttt)
"Proper interest" means interest incurred at a rate not in excess of what a
prudent borrower would have had to pay under market conditions existing at the
time the loan was made.
(uuuu)
"Prospective, reasonable, cost-related reimbursement" means present and future
reimbursement, based on analysis and consideration of historical costs related
to patient care.
(vvvv) "Qualified
medicare beneficiary" or "QMB" means an individual meeting these requirements:
(1) Who is entitled to medicare hospital
insurance benefits under part A of medicare;
(2) whose income does not exceed a specified
percent of the official poverty level as defined by the United States executive
office of management and budget; and
(3) whose resources do not exceed twice the
supplemental security income resource limit.
(wwww) "Readmission" means the subsequent
admission of a consumer as an inpatient into a hospital within 30 days of
discharge as an inpatient from the same or another DRG hospital.
(xxxx) "Related parties" means two or more
parties to a transaction, one of which has the ability to influence the other
or others in a way in which each party to the transaction might fail to pursue
its own separate interests fully. Related parties shall include those related
by family, business, or financial association, or by common ownership or
control. Transactions between related parties shall not be considered to have
arisen through arm's-length negotiations. Transactions or agreements that are
illusory or a sham shall not be recognized.
(yyyy) "Related to the community mental
health center" means that the agency or facility furnishing services to the
community mental health center meets any of these requirements:
(1) Is directly associated or affiliated with
the community mental health center by formal agreement;
(2) governs the community mental health
center; or
(3) is governed by the
community mental health center.
(zzzz) "Residence for the payment of hospice
services" means a hospice consumer's home or the nursing facility in which a
hospice consumer is residing.
(aaaaa) "Revocation statement" means the
statement signed by the consumer that revokes the election of hospice service.
(bbbbb) "Sampling" means the
review process of obtaining a stratified random sample of a subset of cases
from the universe of claims submitted by a specific provider. The sample shall
be used to project the review results across the entire universe of claims for
that provider to determine an overpayment.
(ccccc) "Speech therapy" means treatment
provided by a speech pathologist who has a certificate of clinical competence
from the American speech and hearing association. The treatment shall meet
these requirements:
(1) Be rehabilitative and
restorative in nature;
(2) be
provided following physical debilitation due to acute physical trauma or
physical illness; and
(3) be
prescribed by the attending physician.
(ddddd) "Standard diagnosis-related group
amount" or "standard DRG amount" means the amount computed by multiplying the
group reimbursement rate for the general hospital by the diagnosis-related
group weight.
(eeeee)
"State-operated hospital" means an establishment operated by the state of
Kansas that provides diagnosis and treatment for nonrelated patients and
includes the following:
(1) An organized
medical staff of physicians;
(2)
permanent facilities that include inpatient beds; and
(3) medical services that include physician
services and continuous registered professional nursing services for 24 hours
each day.
(fffff) "Stay
as an inpatient in a general hospital" means the period of time spent in a
general hospital from admission to discharge.
(ggggg) "Swing bed" means a hospital bed that
can be used interchangeably as a hospital, skilled nursing facility, or
intermediate care facility bed, with reimbursement based on the specific type
of care provided.
(hhhhh)
"Targeted case management services" means those services that assist medicaid
consumers in gaining access to medically necessary care. The services shall be
provided by a case manager with credentials specified by the secretary.
(iiiii) "Terminally ill" means
that an individual has a life expectancy of six months or less as determined by
a physician.
(jjjjj) "Timely
filing" means the receipt by the agency or its fiscal agent of a claim for
payment filed by a provider for services provided to a medicaid program
consumer not later than 12 months after the date the claimed services were
provided.
(kkkkk) "Transfer" means
the movement of an individual receiving general hospital inpatient services
from one hospital to another hospital for additional, related inpatient care
after admission to the previous hospital or hospitals.
(lllll) "Transferring hospital" means the
hospital that transfers a consumer to another hospital. There may be more than
one transferring hospital for the same consumer until discharge.
(mmmmm) "Uncollectable overpayment to an
out-of-business provider" means either of the following:
(1) Any amount that is due from a provider of
medical services who has ceased all practice or operations for any medical
services as an individual, a partnership, or a corporate identity, and who has
no assets capable of being applied to any extent toward a medicaid overpayment;
or
(2) any amount due that is less
than its collection and processing costs.
(nnnnn) "Urgent" means that a situation
requires medical treatment within two days of onset, but not through the
emergency room.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.