R410-14-2. Definitions

  (1) The definitions in Rule R414-1 and Section 63G-4-103 apply to this rule.

  (2) The following definitions also apply:

  (a) "Action" means:

  (i) a denial, termination, suspension, or reduction of medical assistance for a recipient;

  (ii) a reduction, denial or revocation of reimbursement for services for a provider;

  (iii) a denial or termination of eligibility for participation in a program, or as a provider;

  (iv) a determination by skilled nursing facilities and nursing facilities to transfer or discharge residents;

  (v) an adverse determination, as defined in Subsection R410-14-2(2)(b);

  (vi) an adverse benefit determination as defined in Subsection R410-14-20(2)(a); or

  (vii) placement of a Medicaid enrollee on the restriction program.

  (b) "Adverse determination" means a determination made in accordance with Sections 1919(b)(3)(F) or 1919(e)(7)(B) of the Social Security Act that the individual does not require the level of services provided by a nursing facility or that the individual does or does not require specialized services.

  (c) "Agency" means Division of Medicaid and Health Financing (DMHF) within the Department of Health, the Department of Human Services (DHS), the Department of Workforce Services (DWS) or any managed health care organization (MCO) that has conducted or performed an action as defined in this rule.

  (d) "Aggrieved person" means any recipient, enrollee, or provider who is affected by an action of an agency.

  (e) "CHEC" means Child Health Evaluation and Care program, which is Utah's version of the federally mandated Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Medicaid child health program.

  (f) "De novo" means anew, or considering the question of a case for the first time.

  (g) "DHS" means the Department of Human Services.

  (h) "DOH" means the Department of Health.

  (i) " DWS" means the Department of Workforce Services.

  (j) "Eligibility Agency" means DWS or DHS or any entity the Agency contracts with to determine medical assistance eligibility.

  (k) "Ex Parte" communications mean direct or indirect communication in connection with an issue of fact or law between the hearing officer and one party only.

  (l) "Grievance" means an expression of dissatisfaction about any matter other than an action as defined in this rule. Grievances may include but are not limited to the quality of care of services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee or failure to respect the rights of an enrollee of an MCO.

  (m) "Grievance system" means the overall system that includes grievances and appeals handled by an MCO and access to the administrative hearing process set out in this rule.

  (n) "Hearing Officer" means solely any person designated by the DMHF Director to conduct administrative hearings pursuant to this rule.

  (o) "Managed Care Organization" or "MCO" means a health maintenance organization, a prepaid mental health plan or a dental managed care plan that contracts with DMHF to provide health, behavioral health or oral health services to Medicaid or CHIP recipients.

  (p) "Medical record" means a record that contains medical data of a medical assistance recipient or enrollee.

  (q) "Provider" means any person or entity that is licensed and otherwise authorized to furnish health care to medical assistance recipients or medical assistance MCO enrollees.

  (r) "Order" means a ruling by a hearing officer that determines the legal rights, duties, privileges, immunities, or other legal interests of one or more specific persons.

  (s) "Scope of service" means medical, oral or behavioral health services set out under R414 as a covered benefit.

  (t) "State fair hearing" means an administrative hearing conducted pursuant to this rule.