Minnesota Administrative Rules
Agency 196 - Human Services Department
Chapter 9505 - HEALTH CARE PROGRAMS
MEDICAL ASSISTANCE PAYMENTS
Part 9505.0175 - DEFINITIONS
Current through Register Vol. 49, No. 13, September 23, 2024
Subpart 1. Scope.
The terms used in parts 9505.0170 to 9505.0475 have the meanings given them in this part.
Subp. 2. Attending physician.
"Attending physician" means the physician who is responsible for the recipient's plan of care.
Subp. 3. Business agent.
"Business agent" means a person or entity who submits a claim for or receives a medical assistance payment on behalf of a provider.
Subp. 4. Clinic.
"Clinic" means an entity enrolled in the medical assistance program to provide rural health clinic services, public health clinic services, community health clinic services, or the health services of two or more physicians or dentists.
Subp. 5. Commissioner.
"Commissioner" means the commissioner of the Minnesota Department of Human Services or the commissioner's designee.
Subp. 6. Covered service.
"Covered service" means a health service eligible for medical assistance payment under parts 9505.0170 to 9505.0475.
Subp. 7. Dentist.
"Dentist" means a person who is licensed to provide health services under Minnesota Statutes, section 150A.06, subdivision 1.
Subp. 8. Department.
"Department" means the Minnesota Department of Human Services.
Subp. 9. Drug formulary.
"Drug formulary" means a list of drugs for which payment is made under medical assistance. The formulary is established under Minnesota Statutes, sections 256B.02, subdivision 8 and 256B.0625.
Subp. 10. Durable medical equipment.
"Durable medical equipment" means a device or equipment that can withstand repeated use, is provided to correct or accommodate a physiological disorder or physical condition, and is suitable for use in the recipient's residence.
Subp. 11. Emergency.
"Emergency" means a condition including labor and delivery that if not immediately diagnosed and treated could cause a person serious physical or mental disability, continuation of severe pain, or death.
Subp. 12. Employee.
"Employee" means a person:
Subp. 13. Health care prepayment plan or prepaid health plan.
"Health care prepayment plan" or "prepaid health plan" means a health insurer licensed and operating under Minnesota Statutes, chapters 60A, 62A, and 62C and a health maintenance organization licensed and operating under Minnesota Statutes, chapter 62D to provide health services to recipients.
Subp. 14. Health services.
"Health services" means the goods and services eligible for medical assistance payment under Minnesota Statutes, sections 256B.02, subdivision 8 and 256B.0625.
Subp. 15. Home health agency.
"Home health agency" means an organization certified by Medicare to provide home health services.
Subp. 16. Hospital.
"Hospital" means an acute care institution defined in Minnesota Statutes, section 144.696, subdivision 3, licensed under Minnesota Statutes, sections 144.50 to 144.58, and maintained primarily to treat and care for persons with disorders other than tuberculosis or mental diseases.
Subp. 17. Inpatient.
"Inpatient" means a person who has been admitted to an inpatient hospital and has not yet been formally discharged. Inpatient applies to a person absent from a hospital on a pass ordered by a physician. For purposes of this definition, a person absent from the hospital against medical advice is not an inpatient during the absence.
Subp. 18. [Repealed, 35 SR 1967]
Subp. 19. Licensed practical nurse.
"Licensed practical nurse" means a person licensed to provide health services under Minnesota Statutes, sections 148.29 to 148.299.
Subp. 20. [Repealed, 35 SR 1967]
Subp. 21. Local agency.
"Local agency" means a county or multicounty agency that is authorized under Minnesota Statutes, sections 393.01, subdivision 7 and 393.07, subdivision 2, as the agency responsible for determining eligibility for the medical assistance program.
Subp. 22. Local trade area.
"Local trade area" means the geographic area surrounding the person's residence, including portions of states other than Minnesota, which is commonly used by other persons in the same area to obtain similar necessary goods and services.
Subp. 23. Long-term care facility.
"Long-term care facility" means a residential facility certified by the Minnesota Department of Health as a skilled nursing facility, an intermediate care facility, or an intermediate care facility for the developmentally disabled.
Subp. 24. Medical assistance.
"Medical assistance" means the program established under title XIX of the Social Security Act and Minnesota Statutes, chapter 256B.
Subp. 25. Medically necessary or medical necessity.
"Medically necessary" or "medical necessity" means a health service that is consistent with the recipient's diagnosis or condition and:
Subp. 26. Medicare.
"Medicare" means the health insurance program for the aged and disabled under title XVIII of the Social Security Act.
Subp. 27. Mental health practitioner.
"Mental health practitioner" means a person who is qualified as specified in Minnesota Statutes, section 245.4871, subdivision 26, to serve a person under age 21, or who is qualified as specified in Minnesota Statutes, section 245.462, subdivision 17, to serve a person at least age 21.
Subp. 28. Mental health professional.
"Mental health professional" means a person who provides clinical services in the treatment of mental illness of an adult and who is qualified in at least one of the ways specified in Minnesota Statutes, section 245.462, subdivision 18, clauses (1) to (4), or a person who provides clinical services in the treatment of the emotional disturbance of a child and is qualified in at least one of the ways specified in Minnesota Statutes, section 245.4871, subdivision 27, clauses (1) to (4), or in the manner specified in the state Medicaid plan and who receives clinical supervision as specified in part 9505.0323, subpart 31.
Subp. 29. Nondurable medical equipment.
"Nondurable medical equipment" means a supply or piece of equipment that is used to treat a health condition and that cannot be reused.
Subp. 30. Nurse practitioner.
"Nurse practitioner" means a registered nurse who is currently certified as a primary care nurse or clinical nurse specialist by the American Nurses Association or by the National Board of Pediatric Nurse Practitioners and Associates.
Subp. 31. On the premises.
"On the premises," when used to refer to a person supervising the provision of the health service, means that the person is physically located within the clinic, long-term care facility, or the department within the hospital where services are being provided at the time the health service is provided.
Subp. 32. Performance agreement.
"Performance agreement" means a written agreement between the department and a provider that states the provider's contractual obligations for the sale and repair of medical equipment and medical supplies eligible for medical assistance payment. An example of a performance agreement is an agreement between the department and a provider of nondurable medical supplies or durable medical equipment as specified in part 9505.0310, subpart 3, items A and B.
Subp. 33. Physician.
"Physician" means a person who is licensed to provide health services within the scope of his or her profession under Minnesota Statutes, chapter 147.
Subp. 34. Physician assistant.
"Physician assistant" means a person who meets the requirements of part 5600.2600, subpart 11.
Subp. 35. Plan of care.
"Plan of care" means a written plan that:
Subp. 36. Podiatrist.
"Podiatrist" means a person who is licensed to provide health services under Minnesota Statutes, chapter 153.
Subp. 37. Prior authorization.
"Prior authorization" means the procedures required in parts 9505.5010 to 9505.5030.
Subp. 38. Provider.
"Provider" means a vendor as specified in Minnesota Statutes, section 256B.02, subdivision 7 that has signed an agreement approved by the department for the provision of health services to a recipient.
Subp. 39. Provider agreement.
"Provider agreement" means a written contract between a provider and the department in which the provider agrees to comply with the provisions of the contract as a condition of participation in the medical assistance program.
Subp. 40. Psychiatrist.
"Psychiatrist" means a physician who can give written documentation of having successfully completed a postgraduate psychiatry program of at least three years' duration that is accredited by the American Board of Psychiatry and Neurology.
Subp. 41. Recipient.
"Recipient" means a person who has been determined by the local agency to be eligible for the medical assistance program.
Subp. 42. Registered nurse.
"Registered nurse" means a nurse licensed under and within the scope of practice of Minnesota Statutes, sections 148.171 to 148.285.
Subp. 43. Residence.
"Residence" means the place a person uses as his or her primary dwelling place, and intends to continue to use indefinitely for that purpose.
Subp. 44. Screening team.
"Screening team" has the meaning given in Minnesota Statutes, section 256B.091.
Subp. 45. Second surgical opinion.
"Second surgical opinion" means the requirement established in parts 9505.5035 to 9505.5105.
Subp. 46. Supervision.
"Supervision," except as specified in item E, means the process of control and direction by which the provider accepts full professional responsibility for the supervisee, instructs the supervisee in his or her work, and oversees or directs the work of the supervisee. The process must meet the following conditions.
Subp. 47. Surgical assistant.
"Surgical assistant" means a person who assists a physician, dentist, or podiatrist in surgery but is not licensed as a physician, dentist, or podiatrist.
Subp. 48. Third party.
"Third party" refers to a person, entity, agency, or government program as defined in part 9505.0015, subpart 46.
Subp. 49. Usual and customary.
"Usual and customary," when used to refer to a fee billed by a provider, means the charge of the provider to the type of payer, other than recipients or persons eligible for payment on a sliding fee schedule, that constitutes the largest share of the provider's business. For purposes of this subpart, "payer" means a third party or persons who pay for health service by cash, check, or charge account.
Subp. 50. Vendor.
"Vendor" means a vendor of medical care as defined in Minnesota Statutes, section 256B.02, subdivision 7. A vendor may or may not be a provider.
Statutory Authority: MS s 245.461 to 245.486; 256B.04; 256B.0625
