Definitions (Repealed)

As used in section 17b-192-1 to section 17b-192-12, inclusive, of the Regulations of Connecticut State Agencies: (1) "Administrative hearing" means the administrative hearing procedure contained in sections 17b-60 to 17b-66, inclusive, of the Connecticut General Statutes; (2) "Administrative services organization" (ASO) means the organization under contract with the Department of Social Services to administer certain health care benefits for members who are eligible for the SAGA program, or the ASO's agent; (3) "Border hospital" means "border hospital" as defined in Section 17b-262-631 (4) of the Regulations of Connecticut State Agencies; (4) "Chronic disease hospital" means "chronic disease hospital" as defined in section 19-13-D1 of the Regulations of Connecticut State Agencies; (5) "Commissioner" means the Commissioner of Social Services appointed pursuant to subsection (a) of section 17b-1 of the Connecticut General Statutes or the Commissioner's agent; (6) "Department" means the Connecticut Department of Social Services or its agent; (7) "Emergency" means a medical condition, including labor and delivery, 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 placing a member's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of a bodily organ or part; (8) "Family planning services" means any medically approved diagnostic procedure, treatment, counseling, drug, supply or device that is prescribed or furnished by a provider to members of child bearing age for the purpose of enabling such members to freely determine the number and spacing of their children; (9) "Federally qualified health center" or "FQHC" means "federally qualified health center" as defined in 42 USC 1396d(l); (10) "Grievance" means a written or verbal request to the ASO from a member for a formal review of an ASO decision related to the denial, reduction, termination or suspension of authorization for payment of service; (11) "Hospital" means an institution as defined in section 19-13-D(1)(b)(1) of the Regulations of Connecticut State Agencies; (12) "Intensive care management" means specialized care management techniques that are undertaken by the ASO when a member has complex health care needs; (13) "Medicaid program" means the program operated by the Department of Social Services pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act; (14) "Medically necessary" means those health services required to prevent, identify, diagnose, treat, rehabilitate or ameliorate a health problem or its effects, or to maintain health and functioning, provided such services are: a) consistent with generally accepted standards of medical practice; b) clinically appropriate in terms of type, frequency, timing, site and duration; c) demonstrated through scientific evidence to be safe and effective and the least costly among similarly effective alternatives, where adequate scientific evidence exists; and d) efficient in regard to the avoidance of waste and refraining from provision of services that, on the basis of the best available scientific evidence, are not likely to produce benefit; (15) "Member" means a client who has been certified by the State of Connecticut as eligible to enroll under the SAGA program; (16) "Member services" means administrative services provided by ASO staff, such as: assisting members with selection of providers, answering members' questions, providing information on how to access services, and responding to complaints and resolving problems informally; (17) "Out-of-network provider" means a provider that has not contracted with the ASO to provide services to SAGA members; (18) "Physician incentive plan" means "physician incentive plan" as defined in 42 CFR 422.208; (19) "Primary care provider" or "PCP" means a licensed health care professional responsible for coordinating the health care needs of members; (20) "Prior authorization" means the approval for the service or delivery of the goods from the ASO or the department before the provider actually provides the service or delivers the goods; (21) "Provider" means an individual, entity or organization that supplies medical or dental health services or goods and has contracted with the ASO to provide services to SAGA members; (22) "Provider network" means the providers contracted with the ASO; (23) "Quality management" means the process of reviewing, measuring and continually improving the processes and outcomes of care delivered; (24) "State Administered General Assistance" or "SAGA" means the program established pursuant to section 17b-192 of the Connecticut General Statutes; (25) "Transportation" means emergency ambulance; and non-emergency medical transportation for radiation oncology, chemotherapy and dialysis; and (26) "Utilization management" means the prospective, retrospective or concurrent assessment of the necessity and appropriateness of the allocation of health care resources and services given, or proposed to be given, to an individual.