Minnesota Administrative Rules

9505.5005 DEFINITIONS.

Subpart 1.

Scope.

The terms used in parts 9505.5000 to 9505.5105 have the meanings given them in this part.

Subp. 1a.

Authorization number.

"Authorization number" means the number issued by:

A.

the department, or an entity under contract to the department, to issue a number to a provider for the provision of a covered health service, as specified in part 9505.5010; or

B.

the medical review agent that establishes that the surgical procedure requiring a second surgical opinion is medically appropriate.

Subp. 1b.

Certification number.

"Certification number" means the number issued by the medical review agent that establishes that all or part of a recipient's inpatient hospital services are medically necessary.

Subp. 2.

Commissioner.

"Commissioner" means the commissioner of the Department of Human Services or an authorized designee.

Subp. 3.

Consultant.

"Consultant" means an individual who is licensed or registered according to state law or meets the credentials established by the respective professional organization in an area of health care or medical service; is employed by or under contract with the Department of Human Services; advises the department whether to approve, deny, or modify criteria for the approval of authorization requests in his or her area of expertise; advises the department on and recommends to the department policies concerning health services and whether health services meet the criteria in part 9505.5045; and performs other duties as assigned.

Subp. 4.

Department.

"Department" means the Minnesota Department of Human Services.

Subp. 5.

Emergency.

"Emergency" means a medical condition that, if not immediately diagnosed and treated, could cause a recipient serious physical or mental disability, continuation of severe pain, or death.

Subp. 6.

Fair hearing.

"Fair hearing" means an administrative proceeding under Minnesota Statutes, section 256.045 and as provided in part 9505.5105, to examine facts concerning the matter in dispute and to advise the commissioner whether the department's decision to reduce or deny benefits was correct.

Subp. 7.

General assistance medical care or GAMC.

"General assistance medical care" or "GAMC" means the health services provided to a recipient under the general assistance medical care program according to Minnesota Statutes, chapter 256D.

Subp. 8.

Health services.

"Health services" means the services and supplies furnished to a recipient by a provider as defined in subpart 16.

Subp. 9.

Investigative.

"Investigative" means:

A.

A health service procedure which has progressed to limited human application and trial, which lacks wide recognition as a proven and effective procedure in clinical medicine as determined by the National Blue Cross and Blue Shield Association Medical Advisory Committee, and utilized by Blue Cross and Blue Shield of Minnesota in the administration of their program.

B.

A drug or device that the United States Food and Drug Administration has not yet declared safe and effective for the use prescribed. For purposes of this definition, drugs and devices shall be those identified in the Food and Drug Act.

Subp. 10.

Local agency.

"Local agency" means a county or a multicounty agency that is authorized under Minnesota Statutes as the agency responsible for the administration of the medical assistance and general assistance medical care programs.

Subp. 11.

Local trade area.

"Local trade area" means the geographic area surrounding the recipient's residence which is commonly used by other persons in the same area to obtain necessary goods and services.

Subp. 12.

Medical assistance or MA.

"Medical assistance" or "MA" means the Medicaid program established by title XIX of the Social Security Act and Minnesota Statutes, chapter 256B. For purposes of parts 9505.5035 to 9505.5105, medical assistance also refers to general assistance medical care and MinnesotaCare unless otherwise specified.

Subp. 12a.

Medical appropriateness or medically appropriate.

"Medical appropriateness" or "medically appropriate" refers to a determination, by a medical review agent, that the recipient's need for a surgical procedure requiring a second medical opinion meets the criteria in Minnesota Statutes, section 256B.0625, subdivisions 1, 4a, and 24.

Subp. 12b.

Medical review agent.

"Medical review agent" means the representative of the commissioner who is authorized by the commissioner to make decisions about second medical opinions under parts 9505.5035 to 9505.5105.

Subp. 13.

Medicare.

"Medicare" means the health insurance program for the aged and disabled established by title XVIII of the Social Security Act.

Subp. 13a.

MinnesotaCare.

"MinnesotaCare" means the program established under Minnesota Statutes, sections 256L.01 to 256L.10.

Subp. 14.

Physician.

"Physician" means a person licensed to provide services within the scope of his or her profession as defined in Minnesota Statutes, chapter 147. For purposes of the second medical opinion requirement in parts 9505.5035 to 9505.5105, physician shall also mean a person licensed to provide dental services within the scope of his or her profession as defined in Minnesota Statutes, section 150A.06, subdivision 1.

Subp. 14a.

Physician adviser.

"Physician adviser" means a physician who is qualified to render an opinion about the surgical procedure as evidenced by the physician's certification or eligibility for certification from the appropriate specialty board if, according to the community standard, the certification or eligibility for certification is required of physicians performing the surgical procedure.

Subp. 14b.

Recipient ID number.

"Recipient ID number" means the unique 8-digit identification number assigned to a recipient who has been determined eligible for MA, GAMC, or MinnesotaCare.

Subp. 15.

Prior authorization.

"Prior authorization" means the written approval and issuance of an authorization number by the department, or by an entity under contract to the department, to a provider for the provision of a covered health service, as specified in part 9505.5010, prior to payment for that service.

Subp. 16.

Provider.

"Provider" means an individual or organization under an agreement with the department to furnish health services to persons eligible for the medical assistance, general assistance medical care, or MinnesotaCare programs.

Subp. 17.

Recipient.

"Recipient" means a person who is eligible for and receiving benefits from the medical assistance, general assistance medical care, or MinnesotaCare programs.

Subp. 17a.

Reconsideration.

"Reconsideration" means a review, as set forth in part 9505.5078, of a second physician adviser's opinion that a surgical procedure is not medically appropriate.

Subp. 18.

Referee.

"Referee" means an individual who conducts fair hearings under Minnesota Statutes, section 256.045 and recommends orders to the commissioner.

Subp. 18a.

Second opinion or second medical opinion.

"Second opinion" or "second medical opinion" means the determination by the medical review agent under parts 9505.5035 to 9505.5105 that a surgical procedure requiring a second medical opinion is or is not medically appropriate.

Subp. 18b.

[Repealed, 20 SR 2405]

Subp. 19.

Working days.

"Working days" means Monday through Friday, excluding state recognized legal holidays.

Statutory Authority:

MS s 256.0625; 256.9352; 256.991; 256B.04; 256D.03; 256L.02

History:

10 SR 842; 13 SR 1688; 19 SR 2433; 20 SR 2405

Published Electronically:

January 14, 2010