DHS 101.03(96m)(b)2.2. Is provided consistent with standards of acceptable quality of care applicable to the type of service, the type of provider and the setting in which the service is provided; DHS 101.03(96m)(b)3.3. Is appropriate with regard to generally accepted standards of medical practice; DHS 101.03(96m)(b)4.4. Is not medically contraindicated with regard to the recipient’s diagnoses, the recipient’s symptoms or other medically necessary services being provided to the recipient; DHS 101.03(96m)(b)6.6. Is not duplicative with respect to other services being provided to the recipient; DHS 101.03(96m)(b)7.7. Is not solely for the convenience of the recipient, the recipient’s family or a provider; DHS 101.03(96m)(b)8.8. With respect to prior authorization of a service and to other prospective coverage determinations made by the department, is cost-effective compared to an alternative medically necessary service which is reasonably accessible to the recipient; and DHS 101.03(96m)(b)9.9. Is the most appropriate supply or level of service that can safely and effectively be provided to the recipient. DHS 101.03(97)(97) “Medically needy” means the group of persons who meet the non-financial eligibility conditions for MA, but whose income exceeds the financial eligibility limits for categorically needy MA groups. Medically needy eligibility exists if applicant’s income does not exceed, for the applicant’s family size, the income limits under. s. 49.47 (4) (c) 1. or 49.471 (7), Stats. DHS 101.03(98)(98) “Medicare” means the health insurance program operated by the U.S. department of health and human services under 42 USC 1395 and 42 CFR subchapter B. DHS 101.03(99)(99) “Modality” means a treatment involving physical therapy equipment that does not require the physical therapist’s personal continuous attendance during the periods of use but that does require setting up, frequent observation, and evaluation of the treated body part by the physical therapist prior to and after treatment. DHS 101.03(100)(100) “Net income” means the amount of the applicant’s income that is left after deductions are made for allowable expenses and income disregards. DHS 101.03(101)(101) “Net market value” means for the purposes of divestment the fair market value of the resource on the date it was disposed of less the reasonable costs of the transaction on the open market. DHS 101.03(101m)(101m) “Networking of existing resources” means the identification of and referral to an agency in the person’s community for any services necessary to overcome the person’s barriers to employment. DHS 101.03(102)(102) “Non-billing performing provider number” means the provider number assigned to an individual who is under professional supervision in order to be an eligible provider. A non-billing provider is not directly reimbursed for services rendered to an MA recipient. DHS 101.03(103)(103) “Non-covered service” means a service, item or supply for which MA reimbursement is not available, including a service for which prior authorization has been denied, a service listed as non-covered in ch. DHS 107, or a service considered by consultants to the department to be medically unnecessary, unreasonable or inappropriate. DHS 101.03(105)(105) “Non-institutional provider” means a provider, eligible for direct reimbursement, who is in single practice rather than group practice, or a provider who, although employed by a provider group, has private patients for whom the provider submits claims to MA. DHS 101.03(106)(106) “Non-legally responsible relative case” or “NLRR case”means a case in which there is no legally responsible caretaker relative in the home for a dependent child defined under s. 49.19 (1) (a), Stats., but where the caretaker of the child is a qualified relative under s. 49.19 (1) (a), Stats. DHS 101.03(107)(107) “Nonprofit agency” means an agency exempt from federal income taxation under section 501 of the internal revenue code of 1954, as amended. DHS 101.03(110)(110) “Nursing home payment formula” means the prospective payment system for nursing home care established annually by the department. DHS 101.03(111)(111) “Occupational therapist” or “OTR” means a person who meets the requirements of s. DHS 105.28 (1), is the primary performing provider of occupational therapy services, is responsible for and signs all billings for occupational therapy services, and is not required to be supervised. DHS 101.03(112)(112) “Occupational therapy procedure” means treatment, with or without equipment, which requires the continuous personal attendance of a registered occupational therapist or a certified occupational therapist assistant. DHS 101.03(114)(114) “Outpatient physical therapy services” means physical therapy services furnished by a provider of these services, a rehabilitation agency or by others under an arrangement with and supervised by the provider or rehabilitation agency, to an individual on an outpatient basis, which may include services to correct a pathological condition of speech. DHS 101.03(114m)(114m) “Palliative care” means treatment provided to persons experiencing the last stages of terminal illness for the reduction and management of pain and other physical and psychosocial symptoms of terminal illness, rather than treatment aimed at investigation and intervention for the purpose of cure. “Palliative care” will normally include physician services, skilled nursing care, medical social services and counseling. DHS 101.03(114p)(d)(d) A man adjudged in a judicial proceeding to be the biological father of a child if the child is a nonmarital child who is not adopted or whose parents do not subsequently marry each other under s. 767.803, Stats. DHS 101.03(114q)(114q) “Participant” means a person who is participating in a health and employment counseling program. DHS 101.03(114r)(114r) “Part-time, intermittent” means skilled nursing and therapy services provided in the home for less than 8 hours in a calendar day. DHS 101.03(115)(115) “Person” means an individual, corporation, partnership, association, trustee, governmental unit or other entity. DHS 101.03(115m)(115m) “Period of eligibility” means nine calendar months from the initial calendar month of participation in a health and employment counseling program. DHS 101.03(116)(116) “Personal care service” means a service enumerated in s. DHS 107.112 (1) when provided by a provider meeting the certification requirements for a personal care provider under s. DHS 105.17. DHS 101.03(117)(117) “Personal care worker” means an individual employed by a personal care provider certified under s. DHS 105.17 or under contract to the personal care provider to provide personal care services under the supervision of a registered nurse. DHS 101.03(118)(118) “Personal needs allowance” means that amount of monthly unearned income identified in s. 49.45 (7) (a), Stats., which may be retained for the personal needs of an institutionalized person. DHS 101.03(119)(119) “Persons with related conditions” means individuals who have epilepsy, cerebral palsy or another developmental disability. DHS 101.03(122m)(122m) “Physically or sensory disabled” means a condition which affects a person’s physical or sensory functioning by limiting his or her mobility or ability to see or hear, is the result of injury, disease or congenital deficiency, and significantly interferes with or limits one or more major life activities and the performance of major personal or social roles. DHS 101.03(123)(123) “Physician” means a person licensed under ch. 448, Stats., to practice medicine and surgery, including a graduate of an osteopathic college who holds an unlimited license to practice medicine and surgery. DHS 101.03(124)(124) “Physician assistant” means a person certified by the department to participate in MA who holds the minimum qualifications specified in s. DHS 105.05 (2). DHS 101.03(124m)(124m) “Plan of care,” for purposes of ss. DHS 105.16, 105.19, 107.11, 107.113 and 107.12, means a written plan of care for a recipient prescribed and periodically reviewed by a physician and developed in consultation with the agency staff which covers all pertinent diagnoses, including mental status, type of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items. If a physician refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan. Orders for therapy services shall include the specific procedures and modalities to be used and the amount, frequency and duration. Orders for therapy services may be developed in accord with the therapist or other agency personnel. Agency personnel shall participate in developing the plan of care. DHS 101.03 NoteNote: The federal poverty guidelines for 1999 were published in the Federal Register, March 18, 1999, pp. 13428-13430. DHS 101.03(126)(126) “Practical nurse” or “LPN” means a person who is licensed as a practical nurse under ch. 441, Stats., or, if practicing in another state, is licensed as a practical nurse by that state. DHS 101.03(127)(127) “Prepaid health plan” or “PHP” means a plan made available by a provider, other than a health maintenance organization, that provides medical services to enrolled recipients under contract with the department on a capitation fee basis. DHS 101.03(129m)(a)(a) A pregnant woman for MA coverage of ambulatory prenatal care and other services, as determined under s. 49.465 (2), Stats. DHS 101.03(129m)(c)(c) A woman diagnosed with breast or cervical cancer or precancerous conditions for MA coverage, as defined under s. 49.473 (3), Stats. DHS 101.03(130)(130) “Preventive or maintenance occupational therapy” means occupational therapy procedures which are provided to forestall deterioration of the patient’s condition or to preserve the patient’s current status. Preventive or maintenance occupational therapy makes use of the procedures and techniques of minimizing further deterioration in areas including, but not limited to, the treatment of arthritic conditions, multiple sclerosis, upper extremity contractures, chronic or recurring mental illness and intellectual disability. DHS 101.03(131)(131) “Preventive or maintenance physical therapy” means physical therapy modalities and procedures which are provided to forestall the patient’s condition from deteriorating or to preserve the patient’s current physical status. Preventive or maintenance physical therapy makes use of the procedures and techniques of minimizing further deterioration in areas including, but not limited to, daily living skills, mobility, positioning, edema control and other physiological processes. DHS 101.03(133)(133) “Primary provider” means a provider who provides health care service in the area in which the recipient resides and is designated by the recipient, with the concurrence of the designated provider, to be the recipient’s primary provider. DHS 101.03(134)(134) “Prior authorization” means the written authorization issued by the department to a provider prior to the provision of a service. DHS 101.03 NoteNote: Some services are covered only if they are authorized by the department before they are provided. Some otherwise covered services must be prior authorized after certain thresholds have been reached.
DHS 101.03(134m)(134m) “Private duty nursing” means RN or LPN services provided to a recipient who requires 8 or more hours of skilled nursing care in a calendar day, as specified in s. DHS 107.12. DHS 101.03(135)(135) “PRO” or “peer review organization” means the organization under contract to the department which makes determinations of medical necessity and reviews quality of services received by recipients of MA, medicare and maternal and child health programs when these recipients are hospitalized. DHS 101.03(136)(136) “Procedure” means a treatment that requires the therapist’s personal attendance on a continuous basis. DHS 101.03(136m)(136m) “Professional services” means the covered services listed in s. DHS 107.08 (4) (d) that are provided by health care professionals to MA recipients who are inpatients of a hospital. DHS 101.03(137)(137) “Provider” means a person who has been certified by the department to provide health care services to recipients and to be reimbursed by MA for those services. DHS 101.03(138)(138) “Provider agreement” means the contract between a provider and the department which sets forth conditions of participation and reimbursement. DHS 101.03(139)(139) “Provider assistant” means a provider whose services must be performed under the supervision of a certified or licensed professional provider. A provider assistant, while required to be certified, is not eligible for direct reimbursement from MA. DHS 101.03(140)(140) “Provider certification” means the process of approving a provider for participation in the MA program, as specified in s. DHS 105.01. DHS 101.03(141)(141) “Provider handbook” means a publication developed by the department for the use of providers which outlines program policies and includes instructions on claim filing and other aspects of participation in MA. DHS 101.03(142)(142) “Provider’s eligibility date” means the first date on which a provider may begin participation in MA which is no earlier than and may be later than the initial date of a signed written application. The applicant has 30 calendar days within which to complete and return the signed application form to the fiscal agent. DHS 101.03(143)(143) “Provider’s initial date of application” means the earliest of the following: DHS 101.03(143)(a)(a) The date on which the department receives a letter from a person requesting an application to be a provider; DHS 101.03(143)(b)(b) The date on which the department receives an unsolicited application form from a person wishing to become a provider; or DHS 101.03(143)(c)(c) The date on which the department receives a person’s rejected claim which was rejected due to an invalid provider number. DHS 101.03(144)(144) “Psychiatric hospital” or “psychiatric facility” means an institution which is primarily engaged in providing, by or under the supervision of a physician, inpatient psychiatric services for the diagnosis and treatment of mental illness which may include services for the diagnosis and treatment of the abuse of alcohol or other drugs. DHS 101.03(145)(145) “Psychotherapy” means the treatment of an individual who is mentally ill or has medically significant emotional or social dysfunctions by a psychotherapy provider. The treatment is a planned and structured program based on information from a differential diagnostic examination and directed at the accomplishment of specified goals. The treatment goals may include removing, modifying, or retarding existing symptoms, mediating disturbed patterns of behavior, and promoting positive personal growth and development by enhancing the ability to adapt and cope with internal and external stresses. DHS 101.03(146)(146) “Psychotherapy provider” means a person certified by the department to participate in MA who holds the minimum qualifications specified in s. DHS 105.22. DHS 101.03(147)(147) “Public agency” means an agency operated by the state or a local government. DHS 101.03(148)(148) “Public health agency” means an administrative organization established by the state or a local government, the primary function of which is to maintain the health of the population served by providing environmental health services, preventive medical service and, when necessary, therapeutic medical services. DHS 101.03(149)(149) “Public health nurse” means a registered nurse who has completed a baccalaureate degree program approved by the national league for nursing for public health nursing preparation or post-registered nurse study which includes content approved by the national league for nursing for public health nursing preparation. DHS 101.03(149m)(149m) “Qualified provider” means a provider who is qualified to determine presumptive eligibility of children, women with breast or cervical cancer or precancerous conditions, and pregnant women for MA coverage, as ascertained by the department in accordance with 42 USC 1396a (a) (47). DHS 101.03(150)(150) “Recipient” means a natural person who is entitled to receive benefits under MA. DHS 101.03(151)(151) “Registered nurse” or “RN” means a person who holds a current certificate of registration as a registered nurse under ch. 441, Stats., or, if practicing in another state, is registered with the appropriate licensing agency in that state.
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