SECTION 354.1121. Definitions

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.

(1) Advanced practice registered nurse--A registered nurse authorized by the Texas Board of Nursing to practice as an advanced practice registered nurse. The term includes a nurse practitioner, nurse-midwife, nurse anesthetist, and clinical nurse specialist.

(2) Ambulance service supplier--A person, firm, or institution approved for and participating in Medicare as an air, ground, or specialized ambulance service supplier or provider.

(3) Ambulatory surgical center--A distinct health care entity that operates exclusively for the purpose of providing certain surgical services to patients not requiring overnight inpatient hospital services. The center must meet the conditions for participation described in §354.1211 of this subchapter (relating to Conditions for Participation) and other applicable state and federal requirements.

(4) Approved laboratory--A laboratory that is independent of a hospital or physician's office and that has been approved for and is participating in Medicare and only for the procedures certified to that laboratory under Medicare.

(5) Billing agent--A business agent as described in 42 CFR 447.10(f).

(6) Claim--A request for payment for authorized benefits on the applicable approved form meeting the established itemization requirements.

(7) Day--With respect to inpatient hospital services, the time period of a day is counted for:

(A) hospital bed occupancy each midnight while under registration in a hospital as an inpatient;

(B) each hospital bed occupancy where admission and discharge occur on the same calendar day while under registration in a hospital as an inpatient.

(8) Doctor--Doctor of chiropractic (chiropractor), doctor of optometry (optometrist), doctor of podiatry (podiatrist), or doctor of dentistry (doctor of dental surgery (DDS), doctor of medical dentistry (DMD), and doctor of dental medicine (DDM)).

(9) Doctor of chiropractic, doctor of optometry, doctor of podiatry, and doctor of dentistry (DDS, DMD, or DDM)--A licensed doctor legally authorized to practice his specialty at the time and place the service is provided.

(10) Eligible provider--An institution, facility, agency, person, partnership, corporation, or association approved for participation in the Texas Medicaid program in accordance with terms of this chapter. "Eligible provider" also includes any person, firm, or institution approved for and participating in Part B Medicare as a supplier or provider of medical services or supplies, who is not otherwise designated as an eligible Title XIX provider, and who meets the requirements stipulated in this definition, except that such eligible provider shall be an eligible Title XIX provider only for Part B Medicare services or supplies and for the Title XIX payment of the deductible and coinsurance liabilities.

(11) Eyeglasses--Eyewear dispensed and delivered that is medically necessary and prescribed by a doctor of optometry or physician, is professionally adjudged to be necessary and appropriate for the lens, age, and sex of the eligible recipient, and significantly improves visual acuity or impedes progression of visual problems. The term "eyeglasses" does not include artificial eyes or any item of eyewear for which benefits are not provided in the rules of the Texas Health and Human Services Commission (HHSC) regarding the Medicaid eyeglass program.

(12) Eyeglass supplier--A person, firm, or institution that has entered into a written agreement with HHSC or its designee as an eyeglass supplier on a form approved by HHSC; provided that the benefits shall be available for eyeglass services and supplies dispensed by an eyeglass supplier only if the fitting, adjustment, and repair of the eyewear involved is performed by a physician, doctor of optometry, or an optician; and provided that an eyeglass supplier is an eligible provider under this program. Such suppliers must accept the benefits paid as stipulated by HHSC as payment in full for the service and supplies involved, except as otherwise provided.

(13) Family planning agency--A facility or institution that has been determined by HHSC or its designee to qualify as a family planning agency under standards of participation established by HHSC, including any amendment of such standards of participation authorized by HHSC. Family planning agencies shall accept as payment in full the amount paid in accordance with the benefits as stipulated by HHSC.

(14) Health insuring agency--An organization legally operating within the state that pays for the cost of certain medical services available under the Title XIX state plan to eligible recipients in exchange for premiums paid by HHSC and which assumes an underwriting risk.

(15) HHSC--The Texas Health and Human Services Commission or its designee.

(16) Hospital--Any institution licensed as a hospital by the appropriate licensing authority but which is not a mental institution, a health resort, nursing home, rest home, or any other institution primarily providing convalescent or custodial care or which is otherwise excluded under this chapter.

(17) Illness--A bodily disorder, bodily injury, disease, or mental disease.

(18) Inpatient--A person registered and assigned a medical record number by a hospital for bed occupancy in that hospital.

(19) Institution for mental diseases (IMD)--As defined in 25 TAC §419.453(17) (relating to Definitions).

(20) Medicaid program--The Texas Medical Assistance Program, a joint federal and state program provided for in Chapter 32, Texas Human Resources Code, and subject to Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq.

(21) Mental disease or disorder--Any condition classified as a neurosis, psychoneurosis, psychopathy, psychosis, or personality disorder.

(22) National provider identifier--The identification number required under §1128J(e) of the Social Security Act (42 U.S.C. §1320a-7k(e)).

(23) Nonmedical public institution--An institution or facility that is either a unit of, or under the administrative control of a state, federal, or local government and that is not approved for participation in the Medicaid program.

(24) Out-of-state hospital--A hospital located outside of the State of Texas that participates as a general or acute care hospital or both under Medicare or Title XIX, or both. Examples of institutions that are excluded are institutions primarily for mental disease or pulmonary care, a health resort, a nursing home, a rest home, or any other institution primarily providing convalescent or custodial care or that is otherwise excluded under this chapter.

(25) Outpatient--A person registered by a hospital for outpatient services but not as an inpatient.

(26) Physician--A doctor of medicine or doctor of osteopathy (MD or DO) legally authorized to practice medicine or osteopathy at the time and place the service is provided.

(27) Physical therapist--A graduate of a program of physical therapy approved by the Commission on Accreditation in Physical Therapy Education (or one of the previously recognized accreditation bodies), and licensed by the state in which the services are performed.

(28) Physical therapist assistant--A person licensed by the appropriate state licensure board as a physical therapist assistant and who provides physical therapy under the direction of a licensed physical therapist.

(29) Physical therapy--Restorative services prescribed by a physician and provided to a recipient by a qualified physical therapist. It includes any necessary supplies and equipment.

(30) Prescription--A signed written or electronic order by a physician or other healthcare practitioner acting within the scope of his or her licensure. This includes a verbal order subsequently countersigned by the practitioner or verified by the pharmacist.

(31) Psychologist--A person who is licensed to practice as a psychologist in the state in which the service is performed.

(32) Recipient month--A calendar month of continuous eligibility for one individual under the Medicaid program. Each month covers eligibility for only one eligible recipient. Multiple recipient months may cover eligibility for one or more eligible recipients or eligibility for the same individual if prior months are involved. Additional months of recipient eligibility may occur due to:

(A) certification of eligibility for up to three months prior to date of application;

(B) eligibility for those individuals who are certified to be eligible recipients after a first of the month;

(C) eligibility certified retroactively;

(D) certification of four months post eligibility for certain individuals in the non-Medicare related aid to families with dependent children coverage group; or

(E) appropriately identified error adjustments.

(33) Respiratory care practitioner--A person certified to practice respiratory care as defined in the Occupations Code, Chapter 604, relating to Respiratory Care Practitioners.

(34) Semiprivate room--A two-bed, three-bed, or four-bed accommodation.

(35) State fiscal year--The 12-month period beginning September 1 and ending August 31.

(36) State plan--The plan for administration of the Medicaid program which is approved by the secretary of health and human services in accordance with the provisions of Title XIX of the Social Security Act, as amended.

(37) Substitute dentist--A doctor of dentistry (DDS, DMD, or DDM) who provides services in place of another dentist of the same license type under a billing arrangement. These arrangements must comply with Medicaid policy, billing, reporting, and documentation requirements.

(38) Therapeutic optometrist--A person certified by the Texas Optometry Board to practice therapeutic optometry in accordance with the Texas Optometry Act. References in this chapter to optometrists include therapeutic optometrists.

(39) Third-party billing vendor--A vendor that submits claims to HHSC, or its designee, for reimbursement on behalf of a provider of medical services under the Medicaid program.

(40) Third-party liability--The resources that an eligible recipient may have which serve as a source of payment for services provided under the Medicaid program.

(41) Title XIX hospital--A hospital that is participating as a hospital under Medicare, that has in effect a utilization review plan approved by HHSC applicable to all eligible recipients to whom it provides services or supplies, and has been designated by HHSC as a Title XIX hospital or a hospital not meeting all of the requirements listed in this definition but which provides services or supplies for which benefits are provided under Medicare, the Social Security Act, §1814(d), or would have been provided under such section had the recipients to whom the services or supplies are provided been eligible for and enrolled under Part A of Medicare, to the extent of such services and supplies only, and then only if such hospital has been designated by HHSC as a Title XIX emergency care only hospital, or has been approved by HHSC to provide emergency hospital services and agrees that the reasonable cost of such services or supplies, as defined in the Social Security Act, §1902(a)(13), will be such hospital's total charge for such services and supplies.

(42) Title XIX spell of illness--With respect to inpatient hospital services, spell of illness is a continuous period of hospital confinement. Successive periods of hospital confinement are considered to be continuous unless the last date of discharge and the date of readmission are separated by at least 60 consecutive days.

(43) Utilization review--The methods and procedures related to the review of utilization of covered care and services with respect to medical necessity and to safeguard against inappropriate utilization of care and services.

Source Note: The provisions of this §354.1121 adopted to be effective May 30, 1977, 2 TexReg 1929; amended to be effective February 7, 1984, 9 TexReg 490; amended to be effective October 8, 1984, 9 TexReg 4975; amended to be effective September 3, 1985, 10 TexReg 3178; amended to be effective September 1, 1988, 13 TexReg 3829; amended to be effective February 19, 1990, 15 TexReg 658; amended to be effective January 23, 1991, 16 TexReg 124; amended to be effective October 1, 1991, 16 TexReg 5076; amended to be effective March 1, 1992, 17 TexReg 694; amended to be effective May 1, 1993, 18 TexReg 2307; transferred effective September 1, 1993, aspublished in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective September 12, 2004, 29 TexReg 8795; amended to be effective July 1, 2011, 36 TexReg 3705; amended to be effective January 8, 2013, 38 TexReg 19; amended to be effective November 25, 2015, 40 TexReg 8200; amended to be effective December 31, 2017, 42 TexReg 7381