Utah Admin. Code R414-29-2 - Definitions
In addition to the definitions in Section R414-1-2, the following definitions apply to this rule:
(1)
"Abuse potential medications" means substances listed in Schedule II-V in 21
CFR 812, Subchapter I, Part B (b)(2) through (5)(c) and Section
58-37-4.2. For purposes of the
Restriction Program, this also includes regulated drugs.
(2) "Access to care" means the timely
availability and adequacy of healthcare services to achieve the best health
outcomes for Medicaid members.
(3)
"Annual review" means a review of a restricted member's records and claims from
the earlier 12 months of Medicaid eligibility and enrollment in the Restriction
Program performed to determine whether the member has adhered to Restriction
Program guidelines during enrollment in the Restriction Program.
(4) "Assigned pharmacy" means the pharmacy
assigned by the department for a restricted member to access pharmacy
services.
(5) "Assigned prescriber"
means a provider authorized by a restricted member's assigned PCP to write
prescriptions for the restricted member.
(6) "Assigned primary care provider" means
the PCP assigned by the department as the provider responsible for coordinating
a restricted member's overall health care.
(7) "Assigned provider" means provider
authorized by the restricted member's assigned PCP to provide services to the
member.
(8) "Concurrently
prescribed" means abuse potential medications that are prescribed by different
prescribers for overlapping periods.
(9) "department" means the Division of
Integrated Healthcare and its contracted accountable care
organizations.
(10) "Emergency
department" means an area of a hospital in which emergency services are
provided 24 hours a day.
(11)
"Member" means a person who is determined eligible for assistance under the
Medicaid program.
(12)
"Non-emergent emergency department visit" means an emergency department visit,
in which the medical condition does not meet the definition of emergency
medical condition, and the services provided do not meet the definition of
emergency service, in accordance with the definitions set forth in Section
R414-1-2.
(13) "Non-affiliated" provider means a
provider who has not entered into a contractual agreement with another provider
to provide similar health care services. This type of provider is neither
closely associated with, belongs to, nor subordinate to another provider within
a provider group practice. It also means a provider who has not been designated
by a principal provider to provide health care services in the temporary
absence of the principal provider.
(14) "Overutilization" means to use medical
services at a frequency or amount that is more than customary.
(15) "Primary care provider" or "PCP" means a
physician, doctor of osteopathic medicine, nurse practitioner, or physician
assistant, who provides, coordinates, or helps a patient access a necessary
range of health care services.
(16)
"Regulated drugs" means drugs that are monitored in the Department of Commerce
Controlled Substance Database but have not been scheduled.
(17) "Restriction case" means the record of
documentation on a member enrolled in the Restriction Program.
(18) "Restriction criteria" means the
criteria used to place a Medicaid member in the Restriction Program, as
described under Section
R414-29-3.
(19) "Restricted member" means a Medicaid
member who is placed in the Restriction Program.
Notes
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