Definitions

The following terms used in 130 CMR 435.000 shall have the meanings given in 130 CMR 435.402 unless the context clearly requires a different meaning. Abuse — a nonaccidental physical injury to an individual inflicted by another person that causes or creates a substantial risk of death or protracted impairment of any bodily organ or function; or the commission of sex offenses against an individual, as defined in the criminal laws of Massachusetts. Administrative Day — a day of hospitalization on which a member's care needs can be met in a setting other than a chronic-disease or rehabilitation hospital, as defined in 130 CMR 435.402, and on which a member is clinically ready for discharge. Admission Screening — screening prior to hospital admission. Agent — the Peer Review Organization (PRO), the hospital's utilization-review coordinator, or other party designated by the Division to act on its behalf in instances when the Division itself does not perform the required function. Chronic-Disease Hospital — a facility, or a unit within a facility, with a majority of its beds licensed by the Massachusetts Department of Public Health to provide chronic-disease services. Concurrent Review — the assessment of the medical necessity for continued hospital stay and for all services provided during such continued stay. Such review may be performed at any time subsequent to the member's admission. Conversion — the assumption by the Division of responsibility for the health-care coverage of a patient who was receiving health-care coverage from a payer other than the Division at the time of hospital admission. Conversion Screening — screening prior to conversion. Day of Discharge — the day on which a member leaves the hospital, regardless of the hour. The day of death is also considered the day of discharge. Discharge Planner — a registered nurse or a social worker who is licensed, or who is eligible for licensure and has submitted an application for licensure to the appropriate Massachusetts board of registration or licensing agency in its state, and whose primary responsibility is discharge planning. Discharge Planning — the coordinated effort of the discharge-planning staff of a hospital to locate appropriate placement for members who no longer require hospitalization. Leave-of-Absence Day — a day during which a bed in a hospital is reserved for a member who leaves the facility and for whom no formal discharge and readmission procedures occur. Length of Stay — the duration of a member's inpatient hospital stay at a Medicare hospital level of care during a medical leave of absence. Managed-Care Per Diem — a daily, all-inclusive fee, after deductions for the patient-paid amount and any third-party payments, paid monthly by the Division for managed-care services. Managed-Care Program — a program under which a chronic-disease or rehabilitation hospital, for a per diem rate paid monthly by the Division, provides or arranges and pays for all managed-care services provided to all inpatients who are MassHealth members and who participate in the hospital's managed-care program in accordance with the terms and conditions stated in the provider agreement between the Division and the hospital. Managed-Care Services — those services mandated by the Massachusetts Department of Public Health as a prerequisite for chronic-disease and rehabilitation bed licensure pursuant to 105 CMR 130.000, and all other services covered by MassHealth, except for acute-level days in an acute hospital. Massachusetts Department of Public Health Hospital — a facility administered or supervised by the Massachusetts Department of Public Health. Medical Absence — an absence from a chronic-disease or rehabilitation hospital that begins on the day a member is transferred to an acute inpatient hospital. Medical Leave of Absence — an inpatient hospital stay of a member who is a resident of a nursing facility for up to 10 consecutive days in a hospital at a Medicare hospital level of care. The day on which a member is transferred from a nursing facility to a hospital for an inpatient stay shall be the first day of the medical leave of absence from the nursing facility. The day on which a member is transferred from a hospital back to a nursing facility or is otherwise discharged to a noninstitutional setting shall not be a medical leave-of-absence day. Medicare Hospital Level of Care — a level of care that meets all criteria, as determined by the Health Care Financing Administration or its agent, for Medicare reimbursement for hospital care. Neglect — failure by a financially able caretaker legally responsible for an individual to provide adequate food, clothing, shelter, education, medical care, proper supervision, or guardianship that results in the individual's present avoidable suffering. The caretaker is considered capable of providing adequate food, clothing, shelter, education, medical care, proper supervision, and guardianship if the caretaker is financially able to do so or is offered other reasonable means to do so. Nursing Facility — a long-term-care institution that meets the provider eligibility and certification requirements of 130 CMR 456.005 or 456.006. Reasonable Distance — generally, 25 miles from the home or usual noninstitutional residence of the member, provided, however, that greater distances may be considered reasonable under certain circumstances, including but not limited to those where: (1) the residence is in a rural area; (2) the member has no family or regular visitors; or (3) the member requires specialized services only available at facilities located at greater distances. Rehabilitation Hospital — a facility, or a unit within a facility, devoted to the provision of comprehensive services to patients whose handicaps are primarily physical, coordinated with efforts to minimize the patient's mental, social, and vocational disadvantages. The course of treatment is limited to the period in which the member continues to make progress toward his or her treatment goal, as described in the member’s service plan. Screening — the assessment of the medical necessity for a hospital admission or continued stay. Utilization-Review Coordinator — an individual responsible for utilization review in a hospital. Working Days — Monday through Friday except for legal holidays.