Okaloosa County BOCC — 2013 meeting #1139 (date undetermined) — MEDICAID ORIGINAL 2009 — reading text

Baker Act- The Florida Mental Health Act, pursuant to ss. 394.451-394.4789, F.S. Behavioral Health Care - Services listed in the Community Behavioral Health Services Coverage & Limitations Handbook and the Targeted Case Management Coverage & Limitations Handbook. Behavioral Health Care involves issues relating to mental health and substance abuse. Business Days - Traditional workdays, which are Monday, Tuesday, Wednesday, Thursday, and Friday, excluding State Holidays. Calendar Days - All seven (7) days of the week. Certification - The process of determining that a facility, equipment or an individual meets the requirements of federal or State law,' or whether Medicaid payments are appropriate or shall be made in certain situations. Children/ Adolescents - Medicaid Beneficiaries under the age of twenty-one (21). Chronic Condition - A Chronic Condition is a medical condition that is long lasting or recurrent. Chronic Conditions require ongoing management for effective long term treatment. Complaint - An expression of dissatisfaction about any matter other than an Action. Possible subjects for Complaint include, but are not limited to, the quality of Transportation Services, the quality of services provided and aspects of interpersonal relationships such as rudeness of a Transportation Provider or employee or failure to respect the Medicaid Beneficiary's rights. A Complaint is resolved at the Point of Contact rather than through filing a formal Grievance. Contracting Officer - The Secretary of the Agency or his/her delegate. Cost - Fully allocated expenses associated with providing Transportation Services to Medicaid Beneficiaries. The Recipient may determine Cost by using the Recipient's approved rate calculation model or a Recipient approved rate calculation model consistently utilized by a Subcontractor. Cost Effective - Economical in terms of the goods or services received for the 2008/2009 Medicaid Non-Emergency Transportation Subcontracted Transportation Provider Contract Page 108 of 117  Covered Services - Those services provided by the Recipient in accordance with this Agreement, and as outlined in Section V, Covered Services, in this Agreement. Also referred to as "Transportation Services." Cultural Competency Plan - A required written plan that the Recipient must maintain in accordance with 42 CFR 438.206. The Cultural Competency Plan describes how the Recipient will ensure that it provides Transportation Services in a culturally competent manner to all Medicaid Beneficiaries, including those with limited English proficiency. Disclosing Entities - The Recipient and any Subcontractors that furnish services or arrange for furnishing services under this Agreement. Emergency Transportation - The provision of Emergency Transportation Services in accordance with Section 409.908(13)(c)(4), F.S. Encounter Data - Encounter Data includes records of Covered Services provided by the Recipient to a Medicaid Beneficiary. Expedited Appeal Process - The process by which the Appeal of an Action is accelerated because the standard time-frame for resolution of the Appeal could seriously jeopardize the Medicaid Beneficiary's life, health, or ability to obtain, maintain, or regain maximum function. External Quality Review (EQR) - The analysis and evaluation by an External Quality Review Organization (EQRO) of aggregated information on Quality, timeliness, and access to the health care services that are furnished to Medicaid Beneficiaries by the Recipient. External Quality Review Organization (EQRO) - An organization that meets the competence ancl independence requirements set forth in Jederalregulations 42 CFR 438.354, and performs EQR, other related activities as set forth in federal regulations, or both. Family Planning Waiver (FPW) - The Family Planning Waiver extends eligibility for family planning services for twenty-four (24) months to postpartum women capable of bearing a child who have lost Medicaid eligibility. Fee-for-Service (FFS) - A method of making payment by which the Agency sets prices for defined medical or allied care, goods, or services. Fiscal Agent - Any corporation, or other legal entity, that enters into a contract with the Agency to receive, process, and adjudicate claims under the Medicaid program. Fiscal Year - The State of Florida's Fiscal Year starts July 1 and ends on June 30. This may be different than the Agreement Year. Florida Medicaid Management Information System (FMMIS) - The information system used to process Florida Medicaid claims and payments to Recipients, and to 2008/2009 Medicaid Non-Emergency Transportation Subcontracted Transportation Provider Contract Page 109 of 117  produce management information and reports relating to the Florida Medicaid program. The State uses this system to maintain Medicaid eligibility data and provider enrollment data. Fraud - An intentional deception or misrepresentation made by a person with the knowledge that the deception results in unauthorized benefit to herself or himself or another person. The term includes any act that constitutes fraud under applicable federal or state law. Grievance - An expression of dissatisfaction about any matter other than an Action. Possible subjects for Grievances include, but are not limited to, the quality of Transportation Services provided and aspects of interpersonal relationships such as rudeness of a Provider or employee or failure to respect the Medicaid Beneficiary's rights. Grievance Procedure - The procedure for addressing Medicaid Beneficiaries' Grievances. Grievance System - The system for reviewing and resolving Medicaid Beneficiary Grievances and Appeals. Components must include a Complaint Procedure, a Grievance Procedure, an Appeal process, and access to the Medicaid Fair Hearing system. Health Care Professional - A physician or any of the following, including, but not limited to: podiatrist, optometrist, chiropractor, psychologist, dentist, physician aSSistant, physical or occupational therapist, therapist assistant, speech-language pathologist, audiologist, Registered Nurse or practical Nurse (including nurse practitioner, clinical nurse speCialist, certified Registered Nurse anesthetist and certified nurse midwife), a Licensed certified social worker, registered respiratory therapist and certified respiratory therapy technician. Hospital - A facility Licensed in accordance with the provisions of Chapter 39S, Florida Statutes or the applicable laws of the state in which the service is furnished. Household - Includes all persons residing at a common address. Information - (i) Structured Data: data that adhere to specific properties and Validation criteria that are stored as fields in database records. Structured queries ca n be created and run against structured data, where specific data can be used as criteria for querying a larger data set; (ii) Document: information that does not meet the definition of structured data; includes text, files, spreadsheets, electronic messages, images of forms, and pictures. Information System(s) - A combination of computing hardware and software that is used in: (a) the capture, storage, manipulation, movement, control, display, interchange, and/or transmission of information (i.e. structured data, which may include digitized audio and video), and documents; and/or (b) the processing of such information for the purposes of enabling and/or facilitating a business process or related transaction .. 2008{2009 Medicaid Non-Emergency Transportation Subcontracted Transportation Provider Contract Page 110 of 117  Insolvency - A financial condition that exists when an entity is unable to pay its debts as they become due in the usual course of business, or when the liabilities of the entity exceeds its assets. Institutional Care Program (ICP) Residents - Medicaid Beneficiaries who are eligible for placement in a facility while their eligibility determination is being processed (e.g., nursing home residents, etc.). Licensed - A facility, equipment, or individual that has formally met State, county, and local requirements, and has been granted a license by a local, State, or federal government entity.. List of Excluded Individuals and Entities (LEIE) - A database maintained by the Department of Health & Human Services, Office of the Inspector General. The LEIE provides information to the public, health care providers, patients and others relating to parties excluded from participation in Medicare, Medicaid, and all other federal health care programs. The LEIE includes the Department of Management Services' List of Excluded Vendors. Managed Care Organization (MCO) - An organization, either for-profit or not-for- profit, in which an organization, such as an HMO, PSN, or EPO, acts as an intermediary between the Medicaid BenefiCiary seeking care and the phYSician. Medicaid - The medical assistance program authorized by Title XIX of the Social Security Act, 42 U.S.c. §1396 et seq., and regulations there under, as administered in the State of Florida by the Agency under 409.901 et seq., F.S. Medicaid Beneficiary - Any individual whom Department of Children and Families (DCF) or the Social Security Administration determines is eligible, pursuant to federal and State law, to receive medical or allied care, goods, or services for which the Agency may make payments under the Medicaid program, and who is enrolled in the Medicaid program. Medicaid Eligibility Vendor System (MEVS) - An entity that provides Medicaid eligibility status to Medicaid providers. A MEVS vendor does not necessarily provide the Non-Emergency Transportation eligibility status of a Medicaid BenefiCiary. Medicaid Reform - The program resulting from Chapter 409.91211, F.S. Medically Needy - A Medicaid BenefiCiary who would qualify for Medicaid but has income or resources that exceed normal Medicaid guidelines. On a month-by-month basis, the State determines the individual's eligibility by subtracting the individual's medical expenses from his/her income; if the remainder falls below Medicaid's income limits, the individual may qualify for Medicaid through the end of the month. Medically Necessary or Medical Necessity - Services that include medical or allied care, goods, or services furnished or ordered to: 2008/2009 Medicaid Non~Emergenc.y Transportation Subcontracted Transportation Provider Contract Page 111 of 117  1. Meet the following conditions: a. Be necessary to protect life, to prevent