Section 16.03.09.010 - DEFINITIONS: A THROUGH HFor the purposes of these rules, the following terms are used as defined below:
01.Abortion. The medical procedure necessary for the termination of pregnancy endangering the life of the woman, or the result of rape or incest, or determined to be medically necessary in order to save the health of the woman.02.Amortization. The systematic recognition of the declining utility value of certain assets, usually not owned by the organization or intangible in nature.03.Ambulatory Surgical Center (ASC). Any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization, and which is certified by the U.S. Department of Health and Human Services as an ASC.04.Audit. An examination of provider records on the basis of which an opinion is expressed representing the compliance of a provider's financial statements and records with Medicaid law, regulations, and rules.05.Auditor. The individual or entity designated by the Department to conduct the audit of a provider's records.06.Audit Reports.a. Draft Audit Report. A preliminary report of the audit finding sent to the provider for the provider's review and comments.b. Final Audit Report. A final written report containing the results, findings, and recommendations, if any, from the audit of the provider, as approved by the Department.c. Interim Final Audit Report. A written report containing the results, findings, and recommendations, if any, from the audit of the provider, sent to the Department by the auditor.07.Bad Debts. Amounts due to provider as a result of services rendered, but which are considered uncollectible.08.Basic Plan. The medical assistance benefits included under this chapter of rules.09.Buy-In Coverage. The amount the State pays for Medicare Part B of Title XVIII of the Social Security Act on behalf of eligible participants.10.Certified Registered Nurse Anesthetist (CRNA). A Licensed Registered Nurse qualified by advanced training in an accredited program in the specialty of nurse anesthesia to manage the care of the patient during the administration of anesthesia in selected surgical situations.11.Claim. An itemized bill for services rendered to one (1) participant by a provider and submitted to the Department for payment.12.CFR. Code of Federal Regulations.13.Clinical Nurse Specialist (CNS). A licensed registered nurse who meets all the applicable requirements to practice as clinical nurse specialist according to the regulations in the state where services are provided.14.CMS. Centers for Medicare and Medicaid Services.15.CMS/Medicare DME Coverage Manual. Medicare Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) Jurisdiction D Supplier Manual.16.Co-Payment. The amount a participant is required to pay to the provider for specified services.17.Cost Report. A fiscal year report of provider costs required by the Medicare program and any supplemental schedules required by the Department.18.Customary Charges. Customary charges are the rates charged to Medicare participants and to patients liable for such charges, as reflected in the facility's records. Those charges are adjusted downward, when the provider does not impose such charges on most patients liable for payment on a charge basis or, when the provider fails to make reasonable collection efforts. The reasonable effort to collect such charges is the same effort necessary for Medicare reimbursement as is needed for unrecovered costs attributable to certain bad debt as described in Chapter 3, Sections 310 and 312, PRM.19.Department. The Idaho Department of Health and Welfare or a person authorized to act on behalf of the Department.20.Director. The Director of the Idaho Department of Health and Welfare or their designee.21.Dual Eligibles. Medicaid participants who are also eligible for Medicare.22.Durable Medical Equipment (DME). Equipment and appliances that: a. Are primarily and customarily used to serve a medical purpose;b. Are generally not useful to an individual in the absence of a disability, illness, or injury;c. Can withstand repeated use;d. Can be reusable or removable;e. Are suitable for use in any setting in which normal life activities take place; andf. Are reasonable and medically necessary for the treatment of a disability, illness, or injury for a Medicaid participant.23.Emergency Medical Condition. A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following:a. Placing the health of the individual, or, with respect to a pregnant woman, the health of the woman or unborn child, in serious jeopardy.b. Serious impairment to bodily functions.c. Serious dysfunction of any bodily organ or part.24.EPSDT. Early and Periodic Screening, Diagnostic, and Treatment services.25.Facility. Facility refers to a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities.26.Federally Qualified Health Center (FQHC). An entity that meets the requirements of 42 U.S.C Section 1395x(aa)(4). The FQHC may be located in either a rural or urban area designated as a shortage area or in an area that has a medically underserved population.27.Fiscal Year. An accounting period that consists of twelve (12) consecutive months.28.Healthy Connections. The primary care case management model of managed care under Idaho Medicaid.29.Home Health Services. Services and items that are: a. Ordered by a physician or licensed practitioner of the healing arts as part of a home health plan of care;b. Performed by a licensed or qualified professional;c. Typically received by a Medicaid participant at the participant's place of residence; andd. Reasonable and medically necessary for the treatment of a disability, illness, or injury for a Medicaid participant.30.Hospital. A hospital as defined in Section 39-1301(a), Idaho Code.31.Hospital-Based Facility. A nursing facility that is owned, managed, or operated by, or is otherwise a part of a licensed hospital.Idaho Admin. Code r. 16.03.09.010