North Dakota Administrative Code
Title 75 - Department of Human Services
Article 75-02 - Economic Assistance
Chapter 75-02-02 - Medical Services
Section 75-02-02-03.2 - Definitions

1. "Certification of need" means a regulatory review process that requires specific health care providers to obtain prior authorization for provision of services for Medicaid applicants or eligible recipients under age twenty-one. Certification of need is a determination of the medical necessity of the proposed services as required for all applicants or recipients under the age of twenty-one prior to admission to a psychiatric hospital, an inpatient psychiatric program in a hospital, or a psychiatric facility, including a psychiatric residential treatment facility. The certification of need evaluates the individual's capacity to benefit from proposed services, the efficacy of proposed services, and consideration of the availability of less restrictive services to meet the individual's needs.

2. "Department" means the North Dakota department of health and human services.

3. "Drug use review board" means the board established pursuant to North Dakota Century Code chapter 50-24.6.

4. "Enrolled in-state provider" means the enrolled medical provider who has assumed responsibility for the advice and care of the recipient.

5. "Exercise program" includes regimens to achieve various improvements in physical fitness and health.

6. "Home health agency" means a public or private agency or organization, or a subdivision of such an agency or organization, which is qualified to participate as a home health agency under title XVIII of the Social Security Act, or is determined currently to meet the requirements for participation.

7. "Indian health service or tribal health facility or clinic" means either a health service facility or clinic operated by the United States department of health and human services Indian health service division or a federally recognized tribal nation that has opted to contract with Indian health service to plan, conduct, and administer one or more individual programs, functions, services, or activities, resulting in tribal health facilities or clinics operated by tribes and tribal organizations under the Indian Self-Determination and Education Assistance Act [Pub. L. 93-638].

8. "Licensed practitioner" means an individual other than a physician who is licensed or otherwise authorized by the state to provide health care services within the practitioner's scope of practice.

9. "Medical emergency" means a medical condition of recent onset and severity, including severe pain, that would lead a prudent layperson acting reasonably and possessing an average knowledge of health and medicine to believe that the absence of immediate medical attention could reasonably be expected to result in serious impairment to bodily function, serious dysfunction of any bodily organ or part, or would place the individual's health, or with respect to a pregnant individual, the health of the individual or their unborn child, in serious jeopardy.

10. "Medically necessary" includes only medical or remedial services or supplies required for treatment of illness, injury, diseased condition, or impairment; consistent with the recipient's diagnosis or symptoms; appropriate according to generally accepted standards of medical practice; not provided only as a convenience to the recipient or provider; not investigational, experimental, or unproven; clinically appropriate in terms of scope, duration, intensity, and site; and provided at the most appropriate level of service that is safe and effective.

11. "Provider" means an individual, entity, or facility furnishing medical or remedial services or supplies pursuant to a provider agreement with the department.

12. "Psychiatric residential treatment facility" is as defined in subsection 13 of section 75-03-17-01.

13. "Recipient" means an individual approved as eligible for Medicaid or children's health insurance program.

14. "Rehabilitative services" means any medical or remedial items or services prescribed for a recipient by the recipient's physician or other licensed practitioner of the healing arts, within the scope of the physician's or practitioner's practice as defined by state law, for the purpose of maximum reduction of physical or mental disability and restoration of the recipient to the recipient's best possible functional level.

15. "Remedial services" includes those services, including rehabilitative services, which produce the maximum reduction in physical or mental disability and restoration of a recipient to the recipient's best possible functional level.

16. "Weight loss program" includes programs designed for reduction in weight, but does not include weight loss surgery.