“Intermediate care services" means services provided by an intermediate care facility.
“Intermittent nursing services" means nursing services provided to a recipient who has a medically predictable recurring need for skilled nursing services. In most instances, this means that the recipient requires a skilled nursing visit at least once every 60 days.
“Laboratory" or “clinical laboratory" means a facility for the microbiological, serological, chemical, hematological, radiobiassay cytological, immunohematological, pathological or other examination of materials derived from the human body, for the purpose of providing information for the diagnosis, prevention or treatment of any disease or assessment of a medical condition.
“Independent laboratory" means a laboratory performing diagnostic tests which is independent both of an attending or consulting physician's office and of a hospital.
“Hospital laboratory" means a laboratory operated under the supervision of a hospital or its organized medical staff that serves hospital patients.
“Physician's office laboratory" means a laboratory maintained by a physician for performing diagnostic tests for his or her own patients.
DHS 101.03 Note
Note: A physician's office laboratory which accepts at least 100 specimens in any category during any calendar year on referral from other physicians is considered an independent laboratory.
“Legally responsible" means a spouse's liability for the support of a spouse or a parent's liability for the support of a child as specified in s. 49.90
“Legend drug" means, for the purposes of MA, any drug requiring a prescription under 21 USC 353
“Medicaid review period" is the calendar month of a medical assistance recipient's application plus 11 calendar months or the medicaid eligibility review calendar month plus 11 calendar months.
“Medical expense" means a cost paid by a medicaid purchase plan recipient for goods or services that have been prescribed or provided by a medical practitioner licensed in Wisconsin or another state. The cost is not reimbursable by another source such as medicare, medical assistance, private insurance or an employer.
“Medical assistance" or “MA" means the assistance program operated by the department under ss. 49.43
, Stats., any services or items under ss. 49.45
, Stats., and this chapter and chs. DHS 102
, or any payment or reimbursement made for these services or items.
“Medical assistance group" or “MA group" means all persons listed on an application for MA who meet nonfinancial eligibility requirements, except that each AFDC recipient, SSI recipient, and each child with no legally responsible relative comprises a separate MA group.
Required to prevent, identify or treat a recipient's illness, injury or disability; and
Is consistent with the recipient's symptoms or with prevention, diagnosis or treatment of the recipient's illness, injury or disability;
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;
Is appropriate with regard to generally accepted standards of medical practice;
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;
Is not duplicative with respect to other services being provided to the recipient;
Is not solely for the convenience of the recipient, the recipient's family or a provider;
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
Is the most appropriate supply or level of service that can safely and effectively be provided to the recipient.
“Medically needy" means the group of persons who meet the non-financial eligibility conditions for AFDC or SSI, but whose income exceeds the financial eligibility limits for those programs.
“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.
“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.
“Net income" means the amount of the applicant's income that is left after deductions are made for allowable expenses and income disregards.
“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.
“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.
“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.
“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.
“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.
“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)
“Nonprofit agency" means an agency exempt from federal income taxation under section 501
of the internal revenue code of 1954, as amended.
“Nursing home payment formula" means the prospective payment system for nursing home care established annually by the department.
“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.
“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.
“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.
“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.
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
“Participant" means a person who is participating in a health and employment counseling program.
“Part-time, intermittent" means skilled nursing and therapy services provided in the home for less than 8 hours in a calendar day.
“Person" means an individual, corporation, partnership, association, trustee, governmental unit or other entity.
“Period of eligibility" means nine calendar months from the initial calendar month of participation in a health and employment counseling program.
“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
“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.
“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.
“Persons with related conditions" means individuals who have epilepsy, cerebral palsy or another developmental disability.
“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.
“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.
“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)
“Plan of care," for purposes of ss. DHS 105.16
, 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 Note
The federal poverty guidelines for 1999 were published in the Federal Register
, March 18, 1999, pp. 13428-13430.
“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.
“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.
“Presumptive eligibility" means eligibility of a pregnant woman for MA coverage of ambulatory prenatal care and other services, as determined under s. 49.465 (2)
, Stats., prior to application and determination of MA eligibility under ss. 49.46 (1)
, and 49.47 (4)
, Stats., and ch. DHS 103
“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.
“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.
“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.
“Prior authorization" means the written authorization issued by the department to a provider prior to the provision of a service.
DHS 101.03 Note
Note: 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.
“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
“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.
“Procedure" means a treatment that requires the therapist's personal attendance on a continuous basis.
“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.
“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.
“Provider agreement" means the contract between a provider and the department which sets forth conditions of participation and reimbursement.
“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.
“Provider certification" means the process of approving a provider for participation in the MA program, as specified in s. DHS 105.01