Mont. Admin. r. 37.82.102 - MEDICAL ASSISTANCE DEFINITIONS
(1)
"AABD" means aid to the aged, blind, and disabled under Title XVI of the Social
Security Act.
(2) "AB" means Aid to
the Blind under Title X of the Social Security Act.
(3) "AFDC" means Aid to Families with
Dependent Children under Title IV-A of the Social Security Act.
(4) "Affiliates" means persons having an
overt or covert relationship such that any one of them directly or indirectly
controls or has the power to control another.
(5) "APTD" means aid to the permanently and
totally disabled under Title XIV of the Social Security Act.
(6) "Categorically needy" means aged, blind
or disabled individuals or families and children:
(a) who are otherwise eligible for Medicaid
and who meet the financial eligibility requirements of section 1951 of the
Social Security Act, SSI, or an optional state supplement; or
(b) whose categorical eligibility is
otherwise provided for in ARM Title 37, chapter 82, subchapters 7, 9, 11, and
13.
(7) "Certification"
means the process by which a governmental or nongovernmental agency or
association evaluates and recognizes an individual, institution or educational
program as meeting predetermined standards.
(8) "Department" means the Montana Department
of Public Health and Human Services.
(9) "Designated review organization" means
either the department or other entity, contracting with the department or
designated by law to determine the medical necessity of medical services
rendered to recipients of public assistance.
(10) "Electronic media claims" means claims
submitted to the Montana Medicaid Program via magnetic tape or another
acceptable electronic media approved by the department in accordance with ARM
37.85.406.
(11) "Emergency service" means inpatient and
outpatient hospital services that are necessary to treat an emergency medical
condition as defined in 42
CFR 489.24(b).
(12) "Families and children" refers to
eligible members of families with dependent children who are financially
eligible under family-related rules in subchapters 7, 11, and 13. In addition,
this group includes individuals under 19 who are not dependent children but who
are financially eligible under the above-cited subchapters. It does not include
individuals under age 21 whose eligibility for Medicaid is based on the
blindness or disability; for these individuals, the SSI-related rules in ARM
Title 37, chapter 82, subchapters 9, 11, and 13 apply.
(13) "Family size", for SSI-related medically
needy, means the number of eligible individuals and responsible relatives
living in the same household unit. Ineligible persons living in the same
household who are not responsible relatives are not counted when determining
family size. For family-related medically needy, "family size" means the number
of eligible individuals in the same household unit. Ineligible persons living
in the same household, including ineligible responsible relatives, are not
counted in determining family size.
(14) "Fiscal agent" means an organization
which processes and pays provider claims on behalf of the department.
(15) "Grounds for sanctions" are fraudulent,
abusive, or improper activities engaged in by providers of medical assistance
services.
(16) "Intern" means a
medical practitioner involved in a period of on-the-job training as part of a
larger educational program.
(17)
"License" means permission granted to an individual or organization by
competent authority to engage in a practice, occupation or activity which would
otherwise be unlawful. It is granted in the state where the practice,
occupation or activity is carried out.
(18) "Medically necessary service" means a
service or item reimbursable under the Montana Medicaid program, as provided in
these rules:
(a) Which is reasonably
calculated to prevent, diagnose, correct, cure, alleviate, or prevent the
worsening of conditions in a patient which:
(i) endanger life;
(ii) cause suffering or pain;
(iii) result in illness or
infirmity;
(iv) threaten to cause
or aggravate a handicap; or
(v)
cause physical deformity or malfunction.
(b) A service or item is not medically
necessary if there is another service or item for the recipient that is equally
safe and effective and substantially less costly including, when appropriate,
no treatment at all.
(c)
Experimental services or services which are generally regarded by the medical
profession as unacceptable treatment are not medically necessary for purposes
of the Montana Medicaid program.
(i)
Experimental services are procedures and items, including prescribed drugs,
considered experimental or investigational by the U.S. Department of Health and
Human Services, including the Medicare program, or the department's designated
review organization or procedures and items approved by the U.S. Department of
Health and Human Services for use only in controlled studies to determine the
effectiveness of such services.
(d) With respect to abortion services
reimbursable under the Montana Medicaid program, subsection (a) is limited by
ARM 37.86.104(11).
(19) "Medically needy" means aged, blind or
disabled individuals or families and children who are otherwise eligible for
Medicaid and whose income is above the prescribed limits for the categorically
needy but within the limits prescribed in ARM Title 37, chapter 82, subchapter
11.
(20) "Montana Medicaid Program"
means the Montana Medical Assistance Program authorized by Title 53, chapter 6,
MCA and Title XIX of the Federal Social Security Act.
(21) "OAA" means Old Age Assistance under
Title I of the Social Security Act.
(22) "OASDI" means Old Age, Survivors, and
Disability Insurance under Title II of the Social Security Act.
(23) "Optional state supplement" means a cash
payment made by the department to an aged, blind or disabled
individual.
(24) "Postpartum
continuous eligibility coverage" means members who are currently enrolled in
Healthy Montana Kids (HMK) or Medicaid may receive 12 months of continuous
postpartum coverage, regardless of any changes in circumstances. The 12-month
postpartum period begins on the last day of a member's pregnancy and extends
through the end of the month in which the 12-month period ends.
(25) "Professional component" means the cost
of professional services of the physician including examination of the patient,
when indicated, performance and/or supervision of the procedure, interpretation
and reporting of the examination and consultation of the referring physician.
It does not include the cost of personnel, materials, equipment or other
facilities.
(26) "Provider" means
an individual, company, partnership, corporation, institution, facility, or
other entity or business association that has enrolled or applied to enroll as
a provider of services or items under the Montana Medicaid program.
(27) "Recipient overpayment" means an amount
of public assistance paid to or on behalf of a recipient in excess of the
amount that is proper.
(28)
"Resident" means a medical practitioner involved in a prolonged period of
on-the-job training which may either be part of a formal educational program or
be undertaken separately after completion of a formal program, sometimes in
fulfillment of a requirement for credentialing.
(29) "Services" means services, items and any
other amounts reimbursable under the Montana Medicaid program.
(30) "SSI" means Supplemental Security Income
under Title XVI of the Social Security Act.
(31) "Suspension of participation" means an
exclusion from participation in the Medicaid Program for a specified period of
time.
(32) "Suspension of payments"
means the withholding of all payments due a provider pending the resolution of
the matter in dispute between the provider and the department.
(33) "Technical component" means the cost of
personnel, materials including visual contrast media and drugs, space,
equipment and other facilities, but does not include the cost of
radioisotopes.
(34) "Termination
from participation" means an exclusion from participation in the Medicaid
program.
(35) "Total value" means
the combined value of the professional component and the technical component of
physician services.
(36)
"Withholding of payments" means a reduction or adjustment of the amounts paid
to a provider on pending and subsequently submitted bills for purposes of
offsetting overpayments previously made to the provider.
Notes
AUTH: 53-2-201, 53-6-113, MCA; IMP: 53-2-201, 53-6-101, 53-6-106, 53-6-107, 53-6-111, 53-6-113, 53-6-131, 53-6-141, MCA
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