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

significant illness or significant disability or to alleviate severe pain; b. Be individualized, specific and consistent with symptoms or confirm diagnosis of the illness or injury under treatment and not in excess of the patient's needs; c. Be consistent with the generally accepted professional medical standards as determined by the Medicaid program, and not be experimental or investigational; d. Be reflective of the level of service that can be furnished safely and for wh ich no equally effective and .more conservative or less costly treatment is available statewide; and e. Be furnished in a manner not primarily intended for the convenience of the Medicaid Beneficiary, the Medicaid Beneficiary's caretaker or the provider. 2. Medically Necessary or Medical Necessity for those services furnished in a Hospital on an inpatient basis cannot, consistent with the provisions of appropriate medical care, be effectively furnished more economically in a Nursing Facility basis or in an inpatient facility of a different type. 3. The fact that a Licensed Health Care Professional has prescribed, recommended, or approved medical or allied goods or services does not, in itself, make such care, goods, or services Medically Necessary, a Medical Necessity, or a Covered Service. Medicare - The medical assistance program authorized by Title XVIII of the Social Security Act. Mile! Mileage - Distance that Transportation Providers log for each Medicaid BenefiCiary. Mile/Mileage starts at the location that the Transportation Provider picks up the Medicaid Beneficiary and ends at the location at which the Transportation Provider delivers the M.edicaid Beneficiary. Neglect - A failure or omission to provide care, supervision, and/or services necessary to maintain a Medicaid Beneficiary's physical and mental health, including but not limited to, food, nutrition, supervision, medical services, and Transportation Services that are essential for the well-being of the Medicaid BenefiCiary. Neglect might be a single incident or repeated conduct that results in, or could reasonably be expected to result in, serious physical or psychological injury, or a substantial risk of death. No Show - If a Medicaid Beneficiary fails to provide a cancellation notice to the Recipient or a Transportation Provider at least twenty-four (24) hours in advance of a scheduled Trip, or the Medicaid BenefiCiary is not available or has decided he/she does not require Transportation Services, then the Recipient shall classify the Medicaid Beneficiary as a No Show. Non-Covered Service - A service that does not qualify as one of the Recipient's Covered Services. 2008/2009 Medicaid Non-Emergency Transportation Subcontracted Transportation Provider Contract Page 112 of 117  Non-Emergency Transportation Services Coverage &. Limitations Handbook (Handbook) - A document that provides information to a Transportation Provider regarding Medicaid Beneficiary eligibility, claims submission and processing, Transportation Provider participation, covered care, goods and services, limitations, procedure codes and fees, and other matters related to participation in the Medicaid program. Nursing Facility - An institutional care facility that furnishes medical or allied inpatient care and services to individuals needing such services. See Chapters 395 and 400, F.S. Outpatient - A patient of an organized medical facility, or distinct part of that facility (such as a Hospital), whom a facility expects to receive, and who does receive, professional services for less than a twenty-four (24) hour period, regardless of the hours of admission, whether or not a bed is used and/or whether or not the patient remains in the facility past midnight. . Overpayment - Includes any amount that is not authorized to be paid by the Medicaid program whether paid as a result of inaccurate or improper cost reporting, improper claiming, unacceptable practices, Fraud, Abuse, or mistake. Point of Contact - Ombudsman, customer service center, call center, or other program that receives Complaints from Medicaid Beneficiaries. Presumptively Eligible Pregnant Women - This program allows staff at County Health Departments (CHDs), Regional Perinatal Intensive Care Centers (RPICCs), and other qualified medical facilities to make a presumptive determination of Medicaid eligibility for low-income pregnant women. This presumptive determination allows a woman to access prenatal care while Department of Children and Families eligibility staff make a regular determination of eligibility. Prior Authorization - The act of authorizing specific services before they are rendered. Protocols - Written guidelines or documentation outlining steps the Recipient, Subcontractors (if any), and Transportation Providers must follow when handling a particular situation, resolving a problem, or implementing a plan to provide Transportation Services. Also referred to as "policies and procedures." Quality - The degree to which a Recipient increases the likelihood of desired health outcomes of its Medicaid Beneficiaries through its structural and operational characteristics and through the provision of Transportation Services that are consistent with current professional knowledge. Quality Improvement (QI) - The process of monitoring and assuring that the delivery of Transportation Services are available, accessible, timely, and provided in sufficient quantity, of acceptable Quality, within established standards of excellence, and appropriate for meeting the needs of Medicaid Beneficiaries. 2008/2009 Medicaid Non·Emergency Transportation Subcontracted Transportation Provider Contract Page 113 of 117  Quality Improvement Program (QIP) - The program designed to ensure the delivery of Transportation Services is appropriate, timely, accessible, and available. Recipient - The entity that has entered into an Agreement with the Agency to provide Non-Emergency Transportation coordination services to Medicaid Beneficiaries. Road Calls - A call to repair or replace a vehicle while en route to pick up a Medicaid Beneficiary and/or while transporting Medicaid Beneficiaries due to a mechanical or other failure, not the result of an accident (e.g., air conditioning broke requiring a replacement vehicle to complete the driver's route, replacing a flat tire, etc.) Routine Trips - Medically Necessary Trips that are not urgent in nature (e.g., doctor's appOintment for an annual checkup). Service Area - The designated geographical area within which the Recipient is authorized by the Agreement to furnish Covered Services to Medicaid Beneficiaries. Service Authorization - The Recipient's approval to render services. The process of authorization must at least include a Medicaid Beneficiary's request for the provision of a service. Span of Control - Information Systems and telecommunications capabilities that the Recipient itself operates or for which it is otherwise legally responsible according to the terms and conditions of this Agreement. The Recipient's Span of Control also includes Systems and telecommunications capabilities outsourced/Subcontracted by the Recipient. State - State of Florida. State Holiday - Includes the following days: New Year's Day, Martin Luther King's Day, Memorial Day, Independence Day, Labor Day, Veterans' Day, Thanksgiving Day and the Friday following, and Christmas Day. Subcontract - An agreement entered into by the Recipient and a subcontractor for provision of administrative services on its behalf. Subcontractor - Any person or entity with which the Recipient has contracted or delegated, by use of a Subcontract, some of its functions, services, or responsibilities for providing Transportation Services under this Agreement. Surface Mail - Mail delivery via land, sea, or air, rather than via electronic transmission. Surplus - Net worth, i.e., total assets minus total liabilities. System Unavailability - As measured within the Recipient's Information Systems Span of Control, when a system user does not get the complete, correct full-screen 2008/2009 Medicaid Non~Emergenc.y Transportation Subcontracted Transportation PrOVider Contract Page 114 of 117  response to an input command within three (3) minutes after depressing the "Enter" or other function key. Systems - See Information Systems. Temporary Assistance for Needy Families (TAN F) - Public financial assistance provided to low-income families. Transportation - An appropriate means of conveyance furnished to a Medicaid Beneficiary to obtain Medicaid compensable services. Transportation Provider - A person or entity that is eligible to provide Medicaid Transportation Services and has a contractual agreement with the Recipient or Subcontractor to provide Medicaid Transportation Services. A Transportation Provider must be Licensed in accordance with the applicable laws of the State in which it furnishes Transportation Services. A Subcontractor may act as a Transportation Provider. Transportation Provider Agreement - An agreement between the Recipient or Subcontractor and a Transportation Provider as described above. Transportation Record - Documents corresponding to Transportation Services furnished by the Recipient. The records may be on paper, magnetic material, film, or other media. In order to qualify as a basis for reimbursement, the records must be dated, legible, and signed or otherwise attested to, as appropriate to the media. Transportation Services - See "Covered Services." Trip -Transport of a Medicaid Beneficiary one way, from pickup to destination for the purpose of receiving Medicai.d compensable services. Urgent Care - Services for conditions, which, though not life-threatening, could result in serious injury or disability unless medical attention is received (e.g., high fever, animal bites, fractures, severe pain, etc.) or substantially restrict a Medicaid Beneficiary's activity (e.g., infectious illnesses, flu, respiratory ailments, etc.), require Transportation Services to medical services in which advance scheduling is not possible (e.g., sudden illness, an accident, or follow up laboratory work or tests), or Hospital/facility inpatient or outpatient discharges after normal business hours. Urgent Trip - A Trip relating to: (1) Urgent Care; (2) Hospital/facility inpatient and outpatient discharges; and (3) Emergency room discharges. Validation - The review of