441—185.1 (234) Definitions.
“Adverse authorization action” means an authorization determination decreasing the requested scope, amount, or duration of services, or denying rehabilitative treatment services.
“Affiliates” means persons having an overt or covert relationship such that any one of them directly or indirectly controls or has the power to control another.
“Agency” means any entity, public or private, which provides or represents itself as providing rehabilitative treatment or supportive services.
“Amount” means the number of units of a service core or level of care within a rehabilitative treatment service.
“Authorization action” means an authorization determination approving rehabilitative treatment services.
“Authorized representative” within the context of rule 441—185.13(234) means that person appointed to carry out audit procedures, including assigned auditors, fiscal consultants, or agents contracted for specific audits or audit procedures.
“Behavioral management for children in therapeutic foster care” means services to design, assess, or revise therapeutic treatment strategies in therapeutic treatment family foster homes in order to meet the specific medical-behavioral health needs of children identified by a licensed practitioner of the healing arts. The focus of the service is to develop an intervention plan with the therapeutic treatment foster family to address the specific medical-behavioral health needs of the child, assess the effectiveness of the treatment strategies and interventions in measurable terms on an ongoing basis, and revise the treatment strategies when they are found not to be addressing the specific medical-behavioral condition of the child.
“Care plan” means the plan developed by the provider and treatment foster family for the interventions to be provided by the treatment foster family in accordance with the provider’s treatment plan.
“Case permanency plan” shall mean the plan identifying goals, needs, strengths, problems, services, time frames for meeting goals and for delivery of the services to the child and parents, objectives, desired outcomes, and responsibilities of all parties involved; and reviewing progress.
“Certification” means the decision made by the department that the provider has met the applicable standards.
“Certified psychiatric mental health nurse practitioner” means a person who meets the requirements of a certified psychiatric mental health nurse and is eligible for certification by the American Nursing Association and is licensed by the state of Iowa to practice nursing as defined in Iowa Code chapter 152.
“Child” means a person under 21 years of age.
“Claim” means each record received by the department or the Iowa Medicaid enterprise that tells the amount of requested payment and the service rendered by a provider to a child and family.
“Clinical record” means a tangible and legible record which meets the criteria established for clinical records set forth in rule 441—185.10(234).
“Community residential setting” means a group care residential setting licensed as a community residential facility under 441—Chapter 114.
“Community residential setting for mentally retarded children” means a group care residential setting licensed as a community residential facility for children with mental retardation licensed under 441—Chapter 116.
“Comprehensive residential setting” means a group care residential setting licensed as a comprehensive residential facility under 441—Chapter 115.
“Comprehensive residential setting for mentally retarded children” means a facility licensed as a comprehensive residential facility for children with mental retardation under 441—Chapter 116.
“Confidence level” means the probability that an overpayment or underpayment rate determined from a random sample of charges is less than or equal to the rate that exists in the universe from which the sample was drawn.
“Deemed status” means an acceptance of an outside body’s review, assessment, and accreditation of a rehabilitative treatment services provider’s functioning and services in lieu of certification based on review and evaluation by the department.
“Department” means the Iowa department of human services.
“Department worker” means the worker who is responsible for providing social casework as described in 441—Chapter 131.
“Duration” means the maximum period of time for which the service core or level of care within rehabilitative treatment service is authorized.
“Enhanced residential treatment” means a treatment program in a facility licensed under 441—Chapter 115.
“Experience in the delivery of child welfare and juvenile justice services” means experience working with families at risk of child abuse, children at risk of delinquency, children who have been abused, children adjudicated CINA or delinquent, and children with emotional or behavioral disorders.
“Experience in the delivery of human services” means paid or volunteer experience providing social casework, therapy, or skill development services to children or families; supervision of children; as well as other experiences providing direct care to children and families. It does not include activities engaged in as part of a practicum or internship for academic credit.
“Extrapolation” means that the total amount of overpayment or underpayment will be estimated by using sample data meeting the confidence level requirement.
“Family” includes the following members:
	  1. 	 Legal spouses (including common law) who reside in the same household.
	  2. 	 Natural, adoptive, or step mother or father, and children who reside in the same household.
	  3. 	 A child who lives alone or who resides with a person, or persons, not legally responsible for the child’s support.
“Family preservation” means treatment services provided in the family preservation program that have duration limited to 60 calendar days, but are expected to last an average of 45 calendar days.
“Family skill development” means services to train or educate parents on specific therapeutic interventions to enable them to meet the specific medical-behavioral health treatment needs of the child including guidance and interventions that address the specific medical-behavioral health needs of the child, techniques for caring for a child with special needs, and guidance and intervention to alleviate a pattern of impaired interactions associated with a specific medical-behavioral need of a child.
“Fiscal record” means a tangible and legible history which documents the criteria established for fiscal records as set forth in subrule 185.102(3).
“Generally accepted auditing procedures” means those procedures published in Standards for Audit of Governmental Organizations, Programs, Activities & Functions, 1988 Edition, by the Comptroller General of the United States.
“Highly structured juvenile program” means a treatment program for adjudicated delinquent youth, aged 15 to 17, licensed as either community residential facilities under 441—Chapter 114 or as comprehensive residential facilities under 441—Chapter 115.
“Imminent risk of placement” means that the family at issue includes one or more children considered by the referral worker to be either at high risk or immediate risk of placement. Cases considered at immediate or high risk of placement are defined as follows:
	  1. 	 Immediate. Immediate-risk cases are those in which the referral worker has determined that a child needs to be placed out of home, at least one family member’s safety is in immediate jeopardy, and either emergency placement procedures or emergency and intensive preventive services need to commence immediately.
	  2. 	 High. High-risk cases are those in which the referral worker has determined that a child needs an out-of-home placement, but the family’s condition is such that the immediate safety of any family member is not jeopardized. Nonemergency placement procedures would commence if some type of preventive services were not provided. These cases may include families already receiving preventive services but for whom the referral worker has determined client progress is such that a continuation of the nonfamily preservation services would not ensure family unity and self-sufficiency upon termination of the services.
“Individual provider” means a person who seeks certification pursuant to rule 441—185.10(234) or who is under contract pursuant to 441—Chapter 152 and who delivers rehabilitative treatment and supportive services independent of a partnership, corporation, agency, governmental unit or any other legal entity.
“Juvenile court officer (JCO)” means a person appointed as a juvenile court officer under Iowa Code chapter 602 and a chief juvenile court officer appointed under Iowa Code chapter 602.
“Level of care” means a level of treatment services within the group care program that is differentiated by the intensity of skill development and therapy services provided, the hours of awake supervision, and the ratio of skill development staff to child. There are four levels of rehabilitative treatment in the group care program:
	  1. 	 Community residential.
	  2. 	 Comprehensive residential.
	  3. 	 Enhanced comprehensive residential.
	  4. 	 Highly structured juvenile program.
“Licensed independent social worker” for purposes of this chapter means a person who is licensed as an independent social worker under Iowa Code chapter 154C in activities which are directed at enhancing or restoring people’s capacity for social functioning, whether impaired by environmental, emotional, or physical factors, with particular attention to the person-in-situation configuration.
“Licensed practitioner of the healing arts” means one of the following who is licensed to practice in the state of Iowa as:
	  1. 	 A psychologist.
	  2. 	 A certified psychiatric mental health nurse practitioner.
	  3. 	 A licensed independent social worker.
	  4. 	 A marital and family therapist.
	  5. 	 A mental health counselor.
“Marital and family therapist” means a person who is licensed to practice marital and family therapy in the state of Iowa pursuant to Iowa Code chapter 154D.
“Mental health counselor” means a person who is licensed to practice mental health counseling in the state of Iowa pursuant to Iowa Code chapter 154D.
“Nonprime programming time” means any period of the day in a group care program other than prime programming time and sleeping time.
“Nonrehabilitative treatment need” means the child and family have a protective, supportive or preventative need for which the child has no identified rehabilitative behavioral health treatment need. Services to address a nonrehabilitative treatment need may be directed at a family member to meet the child’s safety, treatment, or permanency need.
“Nonrehabilitative treatment service” means a service to address the nonrehabilitative treatment need of a child. Nonrehabilitative treatment services are designed either to restore a skill or function or teach a new skill or function to achieve maximum independence and functioning. These services may also be directed toward family members to help them meet the treatment, safety, or permanency needs of a child. Nonrehabilitative treatment services are designed to meet treatment needs in one of the following programs:
	  1. 	 Family-centered program.
	  2. 	 Family preservation program.
“Other adult caretaker” for purposes of the family foster care program means any adult other than a foster parent living in the foster family home who provides care to the foster child on a routine basis in the absence of the foster parent.
“Overpayment” means any payment or portion of a payment made to a provider which is incorrect according to the laws and rules applicable to rehabilitative treatment and supportive services which results in a payment greater than that to which the provider is entitled.
“Physician” means an individual who is a doctor of medicine or osteopathy and is licensed to practice in the state of Iowa pursuant to Iowa Code chapter 148.
“Prime programming time” means any period of the day in a group care program when special attention, supervision, or treatment is necessary; for example, upon awakening in the morning until departure for school, during meals, after school, transition between activities, evenings and bedtime, and on nonschool days such as weekends, holidays, and school vacations.
“Probation” means a specified period of conditional participation in the provision of rehabilitative and supportive services.
“Provider” means any natural person, company, firm, association, or other legal entity seeking certification pursuant to rule 441—185.10(234) or under contract with the department pursuant to this chapter or 441—Chapter 152.
“Psychologist” for the purposes of this chapter means a person who is licensed to practice psychology in the state of Iowa pursuant to Iowa Code chapter 154B.
“Psychosocial evaluation” means services to evaluate the basic strengths of the child and family; assess the emotional needs, health and safety of the child and family; identify the goals and treatment services needed to obtain these goals and expected outcomes; identify the resources available to promote and support these goals; and identify the general functioning of the child.
“Random sample” means a systematic (or every nth unit) sample for which each item in the universe has an equal probability of being selected.
“Referral worker” means the department worker or juvenile court officer who refers the case to the review organization and who is responsible for carrying out the follow-up activities after the service necessity determination and service authorization process is completed.
“Rehabilitative treatment need” means a medical-behavioral health need of a child with a deficit in function or skill that the child lost or never gained as a result of interference in the normal maturational and learning process due to the child or parental dysfunction. The child must have the capability to benefit from the rehabilitative treatment services.
“Rehabilitative treatment services” involves services designed to restore a function or skill that an individual lost or never gained as a result of interference in the normal maturational and learning process due to individual or parental dysfunction. The individual must have the capability to learn the function or skill. Rehabilitative treatment services are designed to address the specific medical-behavioral health needs of the child. Rehabilitative treatment services are designed to address the treatment needs of a child in one of the following programs:
	  1. 	 Family-centered.
	  2. 	 Family preservation.
	  3. 	 Family foster care.
	  4. 	 Group care.
“Related human service field” means psychology; mental health counseling; family therapy; child and family services; family services; child, parent, and community services; human services; sociology; family studies; human relations; criminal justice; chemical dependency counselor program; or nursing. It also includes other degrees in which the student receives educational preparation in the following: therapy and counseling techniques; the development of interview, relationship building, and assessment skills; group dynamics; crisis intervention techniques; social change theories; social system theories; abnormal psychology; sociological concepts and theories as they relate to individuals, families, and groups; and sociological and psychological methods to analyze social problems. Special education, law enforcement administration, political science, and elementary education are not considered related human service fields.
“Restorative living skills development” means rehabilitative services to restore the child’s and family’s ability to function independently in the community on a daily basis. Skills training and supervision include, but are not limited to: food planning and preparation, maintenance of living environment, time and money management, personal hygiene and self-care.
“Review organization” means the entity designated by the department to make rehabilitative treatment services authorization determination.
“Scope” means the rehabilitative treatment service selected and the service cores or level of care within the program that is selected.
“Service authorization” means the process of service necessity determination and service authorization of scope, amount and duration by the review organization.
“Service code” means the identifier which describes services provided.
“Service core” means a set of treatment services within a rehabilitative treatment service delivered to a child and family that addresses the needs of the child and family.
“Site” means a location from which services are delivered, staff report, and records are kept. In the family foster care and group care programs each separately licensed location would be a site.
“Sleeping time” means any period of the day in a group care program in which children are normally sleeping.
“Social skills development” means services to restore a child’s and family’s communication and socialization skills. Interventions would restore a child’s and family’s ability to solve problems, resolve conflicts, develop appropriate relationships with others and develop techniques for controlling behavior.
“Supportive services” means family-centered supportive services as defined in 441—Chapter 182, supervision and home studies in family foster care provided pursuant to 441—Chapter 156, and group care maintenance pursuant to 441—Chapter 156.
“Suspension of payments” means the withholding of all payments due a provider until the resolution of the matter in dispute between the provider and the department.
“Termination from participation” means a permanent exclusion from participation in the provision of rehabilitative treatment and supportive services.
“Therapy and counseling services” means services to halt, control or reverse undue stress and severe social, emotional or behavioral problems that threaten, or have negatively affected the child’s and the child’s family’s stability. Activities under this service can include counseling and therapy to children, groups and families, including interventions to ameliorate difficult behaviors.
“Treatment plan” means a written, goal-oriented plan of service developed for a child and family by the provider.
“Treatment services” means the individual service types included in the services cores or levels of care. These include:
	  1. 	 Restorative living skills development.
	  2. 	 Family skill development.
	  3. 	 Social skills development.
	  4. 	 Therapy and counseling services.
	  5. 	 Psychosocial evaluation.
	  6. 	 Behavioral management for children in therapeutic foster care.
“Underpayment” means any payment or portion of a payment not made to a provider for services delivered to eligible recipients according to the laws and rules applicable to the rehabilitative treatment and supportive services program and to which the provider is entitled.
“Universe” means all items (claims), submitted by a specific provider for payment during a specific time period, from which a random sample will be drawn.
“Withholding of payments” means a reduction or adjustment of the amounts paid to a provider on pending and subsequently submitted claims for purposes of offsetting overpayments previously made to the provider.