Utah Administrative Code
Topic - Health
Title R414 - Integrated Healthcare
Rule R414-29 - Client Review and Restriction Policy
Section R414-29-2 - Definitions

(1) "Abuse potential medications" means those substances listed in Schedule II-V in 21 CFR 812, Subchapter I, Part B (b)(2) through (5)(c) and Section 58-37-4.2.

(2) "Access to care" means the timely availability and adequacy of healthcare services to achieve the best health outcomes for Medicaid members.

(3) "Annual review" means a review of a restricted member's records and claims from the prior 12 months of Medicaid eligibility and enrollment in the Restriction Program performed to determine whether the member has adhered to Restriction Program guidelines during enrollment in the Restriction Program.

(4) "Assigned pharmacy" means the pharmacy assigned by the Department for a restricted member to access pharmacy services.

(5) "Assigned prescriber" means a provider authorized by a restricted member's assigned PCP to write prescriptions for the restricted member.

(6) "Assigned primary care provider" means the PCP assigned by the Department as the provider responsible for coordinating a restricted member's overall health care.

(7) "Assigned provider" means provider authorized by the restricted member's assigned PCP to provide services to the member.

(8) "Concurrently Prescribed" means abuse potential medications that are prescribed by different prescribers for overlapping periods.

(9) "Department" means the Division of Medicaid and Health Financing and its contracted accountable care organizations.

(10) "Emergency department" means an area of a hospital in which emergency services are provided 24 hours a day.

(11) "Member" means a person who is determined eligible for assistance under the Medicaid program.

(12) "Non-emergent emergency department visit" means an emergency department visit, in which the medical condition does not meet the definition of emergency medical condition, and the services rendered do not meet the definition of emergency service, in accordance with the definitions set forth in Section R414-1-2.

(13) "Non-affiliated" provider means a provider who has not entered into a contractual agreement with another provider to provide similar health care services. This type of provider is neither closely associated with, belongs to, nor subordinate to another provider within a provider group practice. It also means a provider who has not been designated by a principal provider to render health care services in the temporary absence of the principal provider.

(14) "Overutilization" means to use medical services at a frequency or amount that is more than customary.

(15) "Primary care provider" or "PCP" means a physician, doctor of osteopathic medicine, nurse practitioner, or physician assistant, who provides, coordinates, or helps a patient access a necessary range of health care services.

(16) "Restriction case" means the record of documentation on a member enrolled in the Restriction Program.

(17) "Restriction criteria" means the criteria used to place a Medicaid member in the Restriction Program, as described under Section R414-29-3.

(18) "Restricted member" means a Medicaid member who is placed in the Restriction Program.