2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Appendix B. DefinitionsTerm Definition Sourcecore service agencies Means multi-service agencies that help to bridge treatment gaps in the child and adultHSD(CSAs)treatment systems, promote the appropriate level of service intensity for members withcomplex behavioral health service needs, ensure that community support services areintegrated into treatment, and develop the capacity for members to have a single point ofaccountability for identifying and coordinating their behavioral health, health, and other socialservices.covered servicescritical incidentcultural competencedesirabledeterminationdual eligible(s)Early and PeriodicScreening, Diagnosis, andTreatment (EPSDT)Means those physical, behavioral health, and long-term care services provided underCentennial Care.Means a reportable incident that may include, but is not limited to:• Abuse, neglect, and exploitation• Abuse is defined as the willful infliction of injury, unreasonable confinement,intimidation, or punishment with resulting physical harm, pain, or mental anguish to aconsumer.• Neglect is defined as the failure to provide goods and services necessary to avoidphysical harm, mental anguish, or mental illness to a consumer.• Exploitation is defined as the deliberate misplacement, exploitation, or wrongful,temporary, or permanent use of a consumer’s belongings or money without theconsumer’s consent.• Death• Unexpected death is a death caused by an accident or an unknown or unanticipatedcause.• Natural/expected death is a death caused by a long-term illness, a diagnosed chronicmedical condition, or other natural/expected conditions resulting in death.• Other reportable incidents• Environmental hazard is defined as an unsafe condition that creates an immediatethreat to life or health of a consumer.• Law enforcement intervention is defined as the arrest or detention of a person by a lawenforcement agency, involvement of law enforcement in an incident or event, orplacement of a person in a correctional facility.• Emergency services refers to the provision of emergency services to a consumer thatresult in medical care that is not anticipated for this consumer, and that would notroutinely be provided by a primary care provider.Means a set of congruent behaviors, attitudes, and policies that come together in a system oragency or among professionals that enables them to work effectively in cross-culturalsituations. Cultural competency involves integrating and transforming knowledge, information,and data about individuals and groups of people into specific clinical standards, serviceapproaches, techniques, and marketing programs that match an individual’s culture toincrease the quality and appropriateness of health care and outcomes.Means “preferred.” The terms “may,” “can,” “should,” “preferably,” or “prefers” identify adesirable or discretionary item or factor (as opposed to “mandatory”).Means the written documentation of a decision by the procurement manager, includingfindings of fact supporting a decision. A determination becomes part of the procurement file.Means individuals who – by reason of age, income and/or disability – qualify for Medicare andfull Medicaid benefits under Section 1902(a)(10)(A) or 1902(a)(10)(C) of the Social SecurityAct, under Section 1902(f) of the Social Security Act, or under any other category of eligibilityfor medical assistance for full benefits.Means the federally required Early and Periodic Screening, Diagnosis and Treatment(EPSDT) program. as defined in Section 1902(r) of the Social Security Act and 42 CFR Part441, Subpart B for members under the age of twenty-one (21). It includes periodiccomprehensive screening and diagnostic services to determine physical and behavioralhealth needs as well as the provision of all medically necessary services listed in Section1905(a) of the Social Security Act even if the service is not available under the state’sMedicaid plan.HSDHSDHSDHSDHSDHSDHSDB-32014 Practitioner and Provider Manual - Ver. 3