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

(1) Access--The ability of an eligible client to obtain health and health-related services, as determined by factors such as: the availability of Texas Health Steps services; service acceptability to the eligible child, pregnant woman, or both; the location of health care facilities and other resources; transportation; hours of facility operation; and length of time available to see the health care provider.

(2) Active Providers--Providers who have reported that they are currently accepting referrals. Inactive providers are those who have reported that they are not accepting referrals or have been placed on inactive status by the department due the department's inability to make contact with them.

(3) Applicant--An agency, organization, or individual who submits an application to the department for approval as a provider of Case Management for Children and Pregnant Women services.

(4) Application process--Submission of an application to provide Case Management for Children and Pregnant Women services, and the department's ensuing review and disposition of the application.

(5) Case manager--An individual qualified under §27.21 of this title (relating to Case Manager Qualifications) who provides Case Management for Children and Pregnant Women services, either as an independent provider, or as an employee or contractor of a case management provider.

(6) Case Management for Children and Pregnant Women services--In reference to the federal regulation (42 C.F.R. §440.169) definition of case management, those services that assist eligible clients in gaining access to necessary medical, social, educational, and other services related to their health condition/health risk or high-risk condition.

(7) Children with a health condition/health risk--Children birth through age 20 who have or are at risk for a medical condition, illness, injury, or disability that results in limitation of function, activities, or social roles in comparison with healthy peers of the same age in the general areas of physical, cognitive, emotional, or social growth and development.

(8) Client--An individual who is eligible for Medicaid and receives services described under this chapter, or the client's parent or legal guardian acting on the client's behalf.

(9) Client choice--Clients are given the freedom to choose a provider, to the extent possible, from among three providers.

(10) Family--A basic unit in society having at its nucleus: one or more adults living together and cooperating in the care and rearing of their biological or adopted children; or a person or persons acting as an individual's family, foster family, or identifiable support person(s).

(11) Health and health-related services--Services which are provided to meet the comprehensive (preventive, primary, tertiary, and specialty) health needs of the eligible client, including, but not limited to, medical and dental checkups, immunizations, acute care visits, pediatric specialty consultations, physical therapy, occupational therapy, audiology, speech language services, mental health professional services, pharmaceuticals, medical supplies, prenatal care, family planning, adolescent preventive health, durable medical equipment, nutritional supplements, prosthetics, eyeglasses, and hearing aids.

(12) High-risk condition--Applies to women who are pregnant and have a medical and/or psychosocial condition(s) that places them and their fetuses at a greater than average risk for complications, either during pregnancy, delivery, or following birth.

(13) Medicaid--Medical assistance program implemented by the State of Texas under the provisions of Title XIX of the Social Security Act, as amended, at 42 U.S.C., §1396, et seq.

(14) Prior authorization--The department's approval of a provider's request for permission to perform a comprehensive visit and follow-up contacts with a client, based on the department's receipt and review of documentation supporting the client's eligibility for services under this chapter. Prior authorization is a condition of reimbursement, not a guarantee of payment.

(15) Provider--An agency or individual approved by the department to provide Case Management for Children and Pregnant Women services and enrolled as a Medicaid provider.

(16) Quality Assurance Review--A review of a provider's client records, internal quality assurance policy, case manager's licensure, outreach materials, and their compliance with the department's rules and policies.

(17) State--The State of Texas.

(18) TMPPM--Texas Medicaid Provider Procedures Manual.

(19) Utilization Review--A review of claims data in which trends have been identified that could indicate potential concerns with the quality of case management services.

Source Note: The provisions of this §27.3 adopted to be effective June 30, 2013, 38 TexReg 3985