Mont. Admin. R. 37.86.4401 - RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, DEFINITIONS
(1) "Allowable
costs" are the costs incurred by an RHC or FQHC, which are reasonable in amount
and necessary and proper to the efficient delivery of services. Allowable costs
are defined in accordance with reasonable cost principles in 42 CFR Parts 405
and 413.
(2) "Baseline PPS rate" is
defined as an RHC's or FQHC's current PPS rate established in accordance with
ARM
37.86.4413,
37.86.4420(2),
37.86.4409,
or
37.86.4410,
as adjusted annually by the Medicare economic index (MEI).
(3) "Category of service" means a type of
Medicaid covered service that is furnished in an RHC or FQHC.
(4) "Change in the scope of service" means a
change that affects the type, intensity, duration, or amount of services
provided by an RHC or FQHC. The change in the scope of service must reasonably
be expected to last at least one year.
(5) "Crossover claim" means a claim for
services provided to Medicare/Medicaid dual eligibles or qualified Medicare
beneficiaries.
(6) "Federally
qualified health center (FQHC)" means an entity as defined in
42
USC 1396d(l)(2). A copy of
the cited statute is available upon request from the Department of Public
Health and Human Services, Health Resources Division, Hospital and Physicians
Services Bureau, 1400 Broadway, P.O. Box 202951, Helena, MT
59620-2951.
(7) "FQHC services" are
as defined in
42
USC 1396d(l)(2).
(8) "Health professional" means services
furnished by a:
(a) physician;
(b) nurse practitioner (NP);
(c) physician assistant (PA);
(d) certified nurse-midwife (CNM);
(e) licensed clinical psychologist (LCP);
(f) licensed clinical social
worker (LCSW);
(g) licensed
professional counselor (LCPC);
(h)
licensed marriage and family therapist (LMFT);
(i) licensed addiction counselor (LAC);
and
(j) clinical pharmacist
practitioner.
(9)
"Incremental change" means a positive or negative adjustment to a baseline PPS
rate.
(10) "Independent entity"
means an RHC or an FQHC that is not a provider-based entity.
(11) "Interim PPS rate" is the rate
established when an RHC or FQHC initially opens and is set in accordance with
ARM
37.86.4413(1)
and (2).
(12) "Provider" means the entity enrolled in
the Montana Medicaid program as an RHC or FQHC.
(13) "Provider-based entity" means an FQHC or
RHC that is an integral and subordinate part of a hospital, skilled nursing
facility, or home health agency that is participating in the Medicare program
and that is operated with other departments of the provider under common
licensure, governance and professional supervision.
(14) "Reporting period" means a period of 12
consecutive months specified by an RHC or FQHC as the period for which the
entity must report its costs and utilization. The reporting period must
correspond to the provider's fiscal year. The first and last reporting periods
may be less than 12 months.
(15)
"Rural health clinic (RHC)" means an entity as defined in
42
USC 1396d(l)(1).
(16) "Rural health clinic (RHC) services" are
as defined in
42 USC
1396(l)(1).
(17) "Temporary PPS rate" is the rate
established in accordance with ARM 37.86.4410.
(18) "Visit" has the meaning set forth in ARM
37.86.4402.
Notes
AUTH: 53-2-201, 53-6-113, MCA; IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA
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