Definitions

For the purposes of sections 17b-262-499 through 17b-262-510 the following definitions shall apply: (1) "Active Treatment" means the definition contained in 42 Code of Federal Regulations (CFR), Part 441, section 441.154. (2) "Acute" means having rapid onset, severe symptoms, and a short course. (3) "Acute Care" means medical care needed for an illness, episode, or injury which requires short-term, intense care, and hospitalization for a short period of time. (4) "Allied Health Professional (AHP)" means a professional or paraprofessional individual who is qualified by special training, education, skills, and experience in mental health care and treatment and shall include, but shall not be limited to: psychologists, social workers, psychiatric nurses, and other qualified therapists. (5) "Certification of Need Review" means an evaluation process for clients under the age of twenty-one who are requesting inpatient admission to a psychiatric hospital. This evaluation is conducted by the department acting as the independent team. (6) "Client" means a person eligible for goods or services under the department's Medical Assistance Program. (7) "Client Age Sixty-Five or Over" means the definition contained in 42 CFR, Part 441, section 441.100. (8) "Client Under Age Twenty-One" means the definition contained in 42 CFR, Part 441, section 441.151. (9) "Department" means the Department of Social Services or its agent. (10) "Elective Admission" means any psychiatric admission to a psychiatric hospital or psychiatric facility that is nonemergency, including urgent admissions and transfers from one facility to another. (11) "HealthTrack Services" means the services described in subsection (r) of section 1905 of the Social Security Act. (12) "HealthTrack Special Services" means medically necessary and medically appropriate health care, diagnostic services, treatment, or other measures necessary to correct or ameliorate disabilities and physical and mental illnesses and conditions discovered as a result of a periodic comprehensive health screening or interperiodic encounter. Such services are provided in accordance with subdivision (5) of subsection (r) of section 1905 of the Social Security Act, and are: (A) services not covered under the State Plan or contained in a fee schedule published by the department; or (B) services covered under the State Plan and contained in a fee schedule published by the department which exceed the limit on the amount of services established by the department that are contained in regulation. (13) "Independent Team" means the definition contained in 42 CFR, Part 441, section 441.153. In addition, the independent team may not include anyone who is related, in any way, to the admitting facility, or who is directly responsible for the care of patients whose care is being reviewed, or has a financial interest in the admitting facility. The department performs the functions of the independent team. (14) "Inpatient" means the definition contained in 42 CFR, Part 440, section 440.2. The client must also be present in the hospital at midnight for the census count. (15) "Interdisciplinary Team" for review of clients under the age of twenty-one, means the definition contained in 42 CFR, Part 441, section 441.156. (16) "Interperiodic Encounter" means any medically necessary visit to a Connecticut Medical Assistance provider, other than for the purpose of performing a periodic comprehensive health screening. Such encounters include, but are not limited to, physician's office visits, clinic visits, and other primary care visits. (17) "Joint Commission on Accreditation of Healthcare Organizations (JCAHO)" means a national, private, not-for-profit organization founded in 1951, which offers accreditation to health care organizations throughout the United States. (18) "Leave of Absence" means a conditional release which is a period of time after admission and prior to the day of discharge, in which the client has been permitted by the attending physician to be absent from the facility premises. (19) "Medical Appropriateness or Medically Appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and is the least costly of multiple, equally-effective, alternative treatments or diagnostic modalities. (20) "Medical Assistance Program" means the medical assistance provided pursuant to Chapter 319v of the Connecticut General Statutes (CGS) and authorized by Title XIX of the Social Security Act. The program is also referred to as Medicaid. (21) "Medical Necessity or Medically Necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or to prevent a medical condition from occurring. (22) "Medical Record" means the definitions contained in 42 CFR, Part 482, section 482.6l, and subsection (d) of section 19-13-D3 of the Regulations of Connecticut State Agencies, which is part of the Public Health Code. (23) "Plan of Care" means the definitions contained in 42 CFR, Part 441, Subpart D, and Part 456, sections 456.180 through 456.181. (24) "Preadmission Review" means a review prior to, or, in the case of an emergency admission, within fourteen days after a client's admission to an inpatient psychiatric facility with the purpose of determining the medical necessity, appropriateness, and quality of the health care services to be delivered, or in the case of an emergency, delivered in the hospital. (25) "Prior Authorization" means approval for the provision of a service or delivery of goods from the department before the provider actually provides the service or delivers the goods. (26) "Provider" means a psychiatric hospital or psychiatric facility. (27) "Provider Agreement" means the signed, written, contractual agreement between the department and the provider of services or goods. (28) "Psychiatric Emergency" means a sudden onset of a psychiatric condition, as determined by a physician, that manifests itself by acute symptoms of such severity that the absence of immediate medical care and treatment in an inpatient psychiatric facility could reasonably be expected to result in serious dysfunction, disability, or death of the client or harm to self or another person by the client. Court commitments and clients admitted on a Physician Emergency Certificate are not automatically deemed to qualify as a psychiatric emergency. (29) "Psychiatric Facility" means an institution which is not a hospital and is accredited by the Joint Commission on Accreditation of Hospitals and Healthcare Organizations (JCAHO), to provide inpatient psychiatric services under the direction of a physician to clients who are under the age of twenty-one or age sixty-five or over, and meets specific conditions contained at 42 CFR, Part 435, section 435.1009. (30) "Psychiatric Hospital" means an accredited or state licensed institution which is engaged in providing hospital level psychiatric services, under the supervision of a physician, for the diagnosis and treatment of mentally ill persons. Specific conditions for psychiatric hospital contained at 42 CFR, Part 482, sections 482.60 through 482.62, and at 42 CFR, Part 435, section 435.1009, shall be implemented. Psychiatric units or beds in a general, acute care hospital are not included in this definition. (31) "Quality of Care" means the evaluation of medical care to determine if it meets the professionally recognized standard of acceptable medical care for the condition and the client under treatment. (32) "Retrospective Review" means the review conducted after services are provided to a client, to determine the medical necessity, appropriateness, and quality of the services provided. (33) "State Plan" means the document which contains the services covered by the Connecticut Medical Assistance Program in compliance with Part 430, Subpart B, of Title 42 of the Code of Federal Regulations. (34) "Transfer" means that an individual is discharged from the hospital or facility and directly admitted to another. (35) "Under the Direction of a Physician" means that health services may be provided by allied health professionals whether or not the physician is physically present at the time that the services are provided. The physician shall: (A) assume professional responsibility for the services provided; (B) assure that the services are medically appropriate; and (C) be readily available within five minutes but not necessarily on the premises. (36) "Urgent Admission" means an elective, nonemergency admission. (37) "Utilization Review" means the evaluation of the necessity, appropriateness, and quality of the use of medical services, procedures, and facilities. Utilization Review evaluates the medical necessity and medical appropriateness of admissions, the services performed or to be performed, the length of stay, and the discharge practices. It is conducted on a concurrent, prospective, or retrospective basis.