441—88.61 (249A) Definitions.
“Accredited” shall mean an entity approved by the division of mental health and disability services of the department to provide mental health services.
“Appeal” shall mean the process defined in 441—Chapter 7 by which a Medicaid member, or the member’s designee, may request review of a certain decision made by the department or the contractor.
“ASAM-PPC-2R” shall mean the American Society of Addiction Medicine Patient Placement Criteria for the Treatment of Substance Related Disorders, Second Edition Revised, published by the American Society of Addiction Medicine in 2001.
“Assertive community treatment (ACT) program” shall mean a program of comprehensive outpatient services provided in the community directed toward the amelioration of symptoms and the rehabilitation of behavioral, functional, and social deficits of persons with severe and persistent mental disorders and persons with complex symptomatology who require multiple mental health and supportive services to live in the community.
“Capitation rate” shall mean the fee the department pays monthly to the contractor for each enrolled Medicaid member for the provision of covered, required, and optional services, whether or not the enrollee received services during the month for which the fee is paid.
“Certification” shall mean the process of determining that a facility, equipment or an individual meets the requirements of federal or state law.
“Clinical decision review” shall mean the process by which enrollees and participating and nonparticipating providers may request a review by the contractor of a decision made by an employee of the contractor regarding the prior authorization, denial, or payment for services.
“Contract” shall mean the contract between the department and the entity or entities selected by the department to implement the Iowa Plan. Contract sections related to Medicaid-funded services shall be interpreted to meet the requirements of the Code of Federal Regulations, Title 42, Part 434 as amended to December 31, 1996. The department of public health also shall be party to the contracts in relationship to the provision of substance abuse services to non-Medicaid persons served through the Iowa Plan.
“Contractor” shall mean each entity with whom the department contracts to provide covered, required and optional services for those members enrolled in the Iowa Plan.
“Coverage group” shall mean a category of members who meet certain common eligibility requirements.
“Covered services” shall mean mental health and substance abuse treatment services reimbursable based on provisions of the Medicaid state plan and paid through the fee-for-service payment system administered by the Iowa Medicaid enterprise.
“Department” shall mean the Iowa department of human services acting in cooperation with the department of public health for governance of the contract.
“Designee” shall mean an organization, person, or group of persons designated by the director to act on behalf of the department in the review or evaluation of services provided through the Iowa Plan.
“Director” shall mean the director of the Iowa department of human services.
“Disenrollment” shall mean the removal of an enrollee from the contractor’s enrollment list either through loss of eligibility or some other cause.
“Emergency services” shall mean those services required to meet the needs of an enrollee who is experiencing an acute crisis of a level of severity requiring immediate treatment where a failure to treat could result in death, injury, or lasting harm to the enrollee or serious danger to others.
“Encounter data” shall mean information reflecting a face-to-face meeting or other billable service furnished by a provider to a person served through the Iowa Plan. Medicaid encounter data must be submitted by the contractor to the department in an electronic format specified by the department.
“Enrollee” shall mean any Medicaid member who is enrolled in the Iowa Plan in accordance with the provisions of the contract.
“Enrollment” shall mean the inclusion of a Medicaid member on a contractor’s Medicaid enrollment file.
“Enrollment area” shall mean the geographical area in which the enrollees that are assigned by the department to the contractor reside.
“Fee-for-service” shall mean the method of making payment for Medicaid services reimbursable under the Medicaid state plan in which reimbursement is based on fees set by the department for defined services. Payment of the fee is based upon delivery of the defined services and is done through the Iowa Medicaid enterprise.
“Grievance” shall mean a nonclinical incident, nonclinical complaint, or nonclinical concern which is received verbally and which cannot be resolved in a manner satisfactory to enrollees or participating or nonparticipating providers by the immediate response of the contractor’s staff member or a nonclinical incident, nonclinical complaint, or nonclinical concern which is received in writing.
“Insolvency” shall mean 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 exceed its assets.
“Integrated mental health services and supports” shall mean individualized mental health services and supports planned jointly by the contractor, the enrollee, and others significant to the enrollee as appropriate, which are not regularly defined services otherwise offered by the contractor.
“Iowa Plan” shall mean the Iowa Plan for Behavioral Health, established by this division as the managed care plan to provide mental health and substance abuse treatment.
“Licensed” shall mean a facility, equipment, individual or entity that has formally met state requirements for licensure and has been granted a license.
“Member” shall mean a person determined eligible for Medicaid.
“Mental health services” shall mean those clinical, rehabilitative, or supportive services provided by an individual, agency, or other entity that is licensed, accredited, certified, or otherwise approved as required by law to treat any mental disorder listed in the International Classification of Diseases—Ninth Edition (ICD-9). At a minimum, covered disorders include the following ranges of the ICD-9: 290-302.9; 306-309.9; and 311-314.9. Additional code ranges may be included in the contract. Mental health services shall include, but not be limited to, those services listed at subrule 88.65(3).
“MHI” shall mean a state mental health institute operated by the department.
“Open panel” shall mean that the contractor shall subcontract with all providers who are appropriately licensed, certified, or accredited to provide covered, required, or optional services, and who meet the credentialing criteria, agree to the standard contract terms, and wish to participate.
“Participating providers” shall mean the providers of mental health and substance abuse services who subcontract with the contractor.
“Prepaid health plan (PHP)” shall mean an entity defined at Section 1903(m)(2)(B)(iii) of the Social Security Act and determined to be a PHP by the department based upon criteria set forth in the Code of Federal Regulations at Title 42, Part 434.20(a)(3), as amended to March 13, 1991.
“Prior authorization” shall mean the process by which an enrollee or a provider obtains approval prior to the initiation or continuation of a service as to the appropriateness of a service. The contractor may require prior authorization as a condition of payment. Prior authorization of a mental health service shall be based on psychosocial necessity. Prior authorization of a substance abuse service shall be based on service necessity.
“Psychosocial necessity” shall mean that clinical, rehabilitative, or supportive mental health services meet all of the following conditions. The services shall be:
	  1. 	 Appropriate and necessary to the symptoms, diagnoses or treatment of a covered mental health diagnosis.
	  2. 	 Provided for the diagnosis or direct care and treatment of a mental disorder.
	  3. 	 Within standards of good practice for mental health treatment.
	  4. 	 Required to meet the mental health needs of the enrollee and not primarily for the convenience of the enrollee, the provider, or the contractor.
	  5. 	 The most appropriate type of service which would reasonably meet the needs of the enrollee in the least costly manner.
The determination of psychosocial necessity shall be made after consideration of the enrollee’s clinical history, including the impact of previous treatment and service interventions; services being provided concurrently by other delivery systems; the potential for services and supports to avert the need for more intensive treatment; the potential for services and supports to allow the enrollee to maintain functioning improvement attained through previous treatment; unique circumstances which may impact the accessibility or appropriateness of particular services for an individual enrollee (e.g., availability of transportation, lack of natural supports including a place to live); and the enrollee’s choice of provider or treatment location.
“Required services” shall mean mental health and substance abuse treatment services and supports which are not reimbursable though the Iowa Medicaid fee-for-service program but which are the contractual responsibility of the contractor.
“Retroactive eligibility” shall mean the period of time consisting of the three months preceding the month in which an application for Medicaid is filed, during which the person may be eligible for Medicaid coverage as determined by the department.
“Routine care” shall mean those clinical, rehabilitative, or supportive mental health or substance abuse services which are typically arranged through regular, scheduled appointments with a provider. Conditions requiring routine care are not likely to substantially worsen or cause damage or disruption to the recipient’s life without immediate intervention.
“Service necessity” shall mean that substance abuse services for the treatment of conditions related to substance abuse meet the following requirements according to the criteria of the ASAM-PPC-2R. The services shall be:
	  1. 	 Appropriate and necessary to the symptoms, diagnoses or treatment of a covered substance abuse diagnosis.
	  2. 	 Provided for the diagnosis or direct care and treatment of a substance abuse disorder.
	  3. 	 Within standards of good practice for substance abuse treatment.
	  4. 	 Required to meet the substance abuse treatment needs of the enrollee and not primarily for the convenience of the enrollee, the provider, or the contractor.
	  5. 	 The most appropriate type of service which would reasonably meet the needs of the enrollee in the least costly manner.
“Substance abuse licensed PMIC” shall mean a psychiatric medical institution for children (PMIC) which also is licensed in accordance with Iowa Code chapter 125 to provide substance abuse treatment services.
“Substance abuse services” shall mean those clinical, rehabilitative, supportive and other services provided in response to and to alleviate the symptoms of any substance abuse disorder listed in the International Classification of Diseases—Ninth Edition (ICD-9), disorders 303 through 305.9, provided by an individual, agency, or other entity that is licensed, accredited, certified, or otherwise approved as required by law to treat any of these substance abuse disorders. Services include, but are not limited to, services listed at subrule 88.65(4).
“Targeted case management services” shall mean MR/CMI/DD case management services targeted to adults with a primary diagnosis of chronic mental illness as defined at rule 441—90.1(249A), with standards set forth in 441—Chapter 24 and Medicaid requirements set forth in 441—Chapter 90.
“Third party” shall mean an individual, entity, or program, excluding Medicaid, that is, may be, could be, should be, or has been liable for all or part of the cost of mental health and substance abuse services related to any medical assistance covered by Medicaid.
“Urgent, nonemergency care” shall mean those clinical, rehabilitative, or supportive services provided for conditions which, although they do not present immediate risk of death, injury, or lasting harm, may risk significant damage or disruption to the recipient’s life or require expeditious treatment to alleviate the prospect that the condition will substantially worsen without immediate intervention.