405 IAC 1-1-1 Definitions

Sec. 1. The following definitions in this section apply throughout this article: (1) "Attending physician" means a physician who is responsible for developing and maintaining the plan of care for a Medicaid patient. (2) "CMS" means the Centers for Medicare and Medicaid Services, a federal agency within the United States Department of Health and Human Services. (3) "CRF/DD" or "CRFs/DD" means a community residential facility or facilities for the developmentally disabled. (4) "CRMNF" means a comprehensive rehabilitative management needs facility as defined in 460 IAC 9-1-2. (5) "ICF/IID" or "ICFs/IID" means an institution or institutions for individuals with intellectual disabilities, as described in IC 16-29-4-2, or a medical institution or that portion thereof providing such care, which is qualified as such an institution pursuant to the provisions of Title XIX of the Social Security Act. (6) "IMFCU" means the Medicaid fraud control unit established by the Indiana attorney general under the authority of IC 4-6-10. (7) "ISDH" means the state department of health as defined in IC 16-19. (8) "Medicaid" means that program described by IC 12-15 and this title, in which the office administers benefits and makes payments to providers for covered services provided to members. (9) "Member" means an individual who has been determined by the office to be eligible for payment of covered services pursuant to IC 12-15. (10) "Nursing facility" means a comprehensive care facility licensed under IC 16-28, or a hospital based long term care facility licensed under IC 16-21 and enrolled as a Medicaid provider. (11) "Nursing facility services" has the meaning set forth in 405 IAC 5-31-1.1. (12) "Office" means the Indiana family and social services administration and its offices, divisions, or designees. (13) "Parameter" means the maximum amount or duration, or both, of a service within appropriate limits for which payment may be made without prior authorization or exception due to medical necessity or contraindications. (14) "Prior authorization" has the meaning set forth in 405 IAC 5-2-20. (15) "Provider" means an individual, state agency, local agency, corporate entity, or business entity that has been enrolled in Medicaid pursuant to 405 IAC 1-1.4-3. (16) "Provider manual" means the interpretive document or documents issued by the office to providers to inform them of their obligations under Medicaid to which they must conform to retain their provider status and receive payment for appropriate services, and to provide them essential information for understanding Medicaid as it relates to the services for which they are qualified to provide under the state statutes. (17) "Third party" means an insurer, individual, institution, corporation, or public or private agency who is or may be liable to pay all or part of the medical costs of injury, disease, or disability of an applicant or recipient of Medicaid. (18) "Usual and customary charge" means the amount a provider offers to charge the general public for a service or supply, including applicable offered discounts. General public does not include individuals who are enrolled in or a member of an insurance plan that covers the services or supplies in question, or receive a discount of the services or supplies through a program with selective criteria that disqualify certain individuals from eligibility in the program.