Definitions Related to Sanctions

9010 – Definitions Related to Sanctions (Rev. 24, Issued: 02-12-16, Effective: 03-14-16, Implementation: 03-14-16) Dentist is limited to licensed doctors of dental surgery or dental medicine. Economically means the services are provided at the least expensive, medically appropriate type of setting or level of care available. Exclusion means that items and services furnished or ordered (or at the medical direction or on the prescription of a physician) by a specified health care practitioner, provider, or other person during a specified period are not reimbursed under titles V, XVIII, XIX, or XX of the Social Security Act and all other Federal non-procurement programs. Federal Health Care Program means any plan or program that provides health benefits, whether directly or indirectly, through insurance, or otherwise, which is funded directly or in whole part by the United States Government or any State health care program in accordance with 1128B(f)and (h) of the Act Gross and flagrant violation means a violation of an obligation has occurred in one or more instances that presents an imminent danger to the health, safety, or well-being of a program patient or places the program patient unnecessarily in high-risk situations. Health care service or services means services or items for which payment may be made (in whole or in part) under the Medicare or State health care programs. Health professional shortage area (HPSA) refers to an area designated by the HHS Secretary and defined in 42 CFR 5.2. Medicare Health Plan(s)(MHP): For the purpose of this chapter, this is a collective reference to Medicare Part C Health Plans (Medicare Health Plans), Medicare Part D Drug Plans, Cost Plans, and Health Care Prepayment Plans (HCPPs). Metropolitan Statistical Area refers to an area defined by the Executive Office of Management and Budget. Obligation means any of the obligations specified in §1156(a) of the Act and 42 CFR §1004.10. Other person means a hospital, another health care facility, an organization, or an agency that provides health care services or to which payment may be made (in whole or in part) under the Medicare or State health care programs. Pattern of care means that the care under question has been demonstrated in more than three instances, each of which involved different admissions. Pharmacy professional is a term limited to individuals who are licensed or registered to provide pharmaceutical services. Podiatric professional is a term limited to licensed doctors of podiatric medicine. Practice area means the location where more than 50 percent of the practitioner’s or other person’s patients are seen. Practitioner means a physician or other health care professional licensed under State law to practice his/her profession. Primary medical care professional is a term limited to: (i) Licensed doctors of medicine and doctors of osteopathy providing direct patient care who practice in the fields of general or family practice, general internal medicine, pediatrics, obstetrics and gynecology, surgery, and any other specialty that is not accommodated by the remaining specialty HPSA designator, or (ii) Facilities where care and treatment is provided to patients with health problems other than mental disorders. Pro area/QIO area means the geographic area subject to review by a particular QIO. Provider means a hospital or other health care facility, agency, or organization. Psychiatric professional is a term limited to licensed doctors of medicine who limit their practice to psychiatry or to those facilities where care and treatment is limited to patients with mental disorders. Reporting Threshold means a practitioner or other person has either (a) failed substantially to comply with any obligation in a substantial number (three or more) of admissions, or (b) grossly and flagrantly violated any obligation in one or more instances. Rural means any area outside an urban area. Rural health professional shortage area means any health professional shortage area located outside a Metropolitan Statistical Area. Sanction means an exclusion or monetary penalty that the HHS Secretary may impose on a practitioner or other person as a result of a recommendation from a QIO. Serious risk includes situations that may involve the risk of unnecessary treatment, prolonged treatment, and lack of treatment, incorrect treatment, medical complication, premature discharge, physiological or anatomical impairment, disability, or death. State health care program means a State plan approved under title XIX, any program receiving funds under title V or from an allotment to a State under such title, or any program receiving funds under title XX or from an allotment to a State under such title. Substantial violation in a substantial number of cases means a pattern of providing care, as defined in this section that is inappropriate, unnecessary, or does not meet recognized professional standards of care, or is not supported by the necessary documentation of care as required by the QIO. Urban refers to a Metropolitan Statistical Area as defined by the Executive Office of Management and Budget. Vision care professional is a term limited to licensed doctors of medicine who limit their practice to ophthalmology and to doctors of optometry.