Action – The denial or limited authorization of a requested service including: 1) Denial of limited authorization of requested services, including the type or level of service; 2) The reduction, suspension, or termination of a previously authorized service; 3) The denial, in whole or in part, of payment for a service; 4) The failure to provide a service in a timely manner; or 5) The failure of a contractor to act within the timeframes required for standard and expedited resolution of appeals and standard disposition of grievances; and 6) Denial of a rural CRS recipient's request to obtain services outside the CRS Contractor's network under 42 C.F.R. § 438.52(b)(2)(ii), when the CRS Contractor and its subcontractors is the only Contractor in the rural area.
Administrative Hearing – A hearing under A.R.S. Title 41, Chapter 6, Article 10 (also called State Fair Hearing).
Advance Directives – A written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated that clearly specifies how medical decisions affecting an individual are to be made if they are unable to make them or to authorize a specific person to make such decisions for them.
Ambulation Assistive Devices – Means walkers, canes, and crutches.
Americans with Disabilities Act (ADA) – A Public Law 101-336 enacted July 26, 1990. The ADA prohibits discrimination and ensures equal opportunity for persons with disabilities in employment, state and local government services, public accommodations, commercial facilities, and transportation.
Appeal (Standard) – An appeal which must be resolved no later than thirty (30) days from the date of receipt of the appeal unless an extension is in effect.
Appeal (Expedited) – An appeal where the CRS Contractor determines (for a request from the CRS recipient), or provider (in making the requests on the CRS recipient's behalf indicates) that the standard resolution timeframe could jeopardize the CRS recipient's life or health or ability to attain, maintain, or regain maximum function. The CRS Contractor shall resolve all expedited appeals not later than three (3) business days from the date the CRS Contractor receives the appeal (unless an extension is in effect) and shall make reasonable efforts to provide oral notice to a CRS recipient regarding an expedited resolution appeal.
Applicant – An individual who has requested enrollment into the CRS program and for which CRS has received a written, signed, and dated application.
Arizona Administrative Code (AAC) – State regulations established pursuant to relevant statutes.
Arizona Health Care Cost Containment System (AHCCCS) – AHCCCS is the system through which Arizona's Medicaid (Title XIX), KidsCare (Title XXI), and the Arizona Long Term Care System (ALTCS) programs are delivered. AHCCCS is the State agency that oversees the Title XIX and Title XXI programs.
Arizona Long Term Care System (ALTCS) – A program under AHCCCS that delivers long term, acute, behavioral health care and case management services to eligible members, as authorized by ARS §36-2932 et seq.
Arizona Physicians Independent Physicians Association Children's Rehabilitative Services (APIPA-CRS) – Is the contracted provider administering the CRS program.
Care Coordination Services – Includes: 1. Coordination of CRS health care through multi-specialty, interdisciplinary approach to care, 2. Coordination of member health care needs through a Service Plan 3. Collaboration with providers, communities, agencies, service systems, members, and families; 4. Sharing information with other appropriate professionals, with the member's or family's consent; 5. Coordination, communication, and support services designed to manage the transition of care for a member.
Child life Services – Include organization of individual, family, or group activities designed to reduce the member's and family's fear of the nature of the illness, medical care, and procedures.
Children's Rehabilitative Services (CRS) – A program that provides medical treatment, rehabilitation, and related support services to eligible individuals who have certain medical, disabling, or potentially disabling conditions, that have the potential for functional improvement through medical, surgical, or therapeutic modalities.
Covered Services – Health, medical, rehabilitative, and support services to be delivered by the CRS Contractor and the CRS Contractor's network as delineated in A.A.C. Title 9, Chapter 7, Article 4 et seq.
CRS Clinic or Multi-Specialty, Interdisciplinary Clinic or MSIC – An established facility where specialists from multiple specialties meet with Recipients and their families for the purpose of providing interdisciplinary services to treat the Recipient's CRS condition.
CRS Condition – A disease, disorder or condition that qualifies for CRS coverage as identified in A.A.C. Title 9, Chapter 7, Article 2.
CRS Medical Director – The physician appointed by the CRS Contractor to make medical decisions about the medical eligibility of applicants and the medical care provided to recipients assigned to the CRS Contractor. The Medical Director also may provide medical advice and counsel to CRSA and to the CRS Contractor and interface with medical directors of other agencies and health plans on care coordination issues.
CRS Recipient (Recipient) – An individual who meets CRS eligibility requirements and is enrolled in CRS.
CRS Provider – A CRS Contractor or its subcontractor who provide CRS covered services to a recipient.
Diagnosis – A determination or identification of a disease or condition that is confirmed by a physician.
Disabling – Physical impairments that limit one or more major life activities such as: caring for oneself; performing manual tasks; walking; seeing; hearing; speaking; breathing; learning; and working.
Durable Medical Equipment (DME) – Adaptive aids and devices, adaptive wheelchairs and ambulation assistive devices.
Durable Medical Equipment (DME), Customized – Equipment that has been altered or built to specifications unique to a recipient's medical needs and which, most likely, cannot be used or reused to meet the needs of another individual.
Eligible – Any individual determined by the CRS Medical Director or his or her designee to have a CRS covered condition, and meets residency, age, and citizenship requirements.
Enrolled – An enrolled recipient is an individual who has been determined eligible and has been granted entry to the CRS program.
Ex-Recipient or Disenrolled Recipient – An individual who is no longer enrolled in the CRS Program.
Field Clinic– A "clinic" consisting of single specialty health care providers who travel to health care delivery settings closer to Members and their families than the MSICs to provide a specific set of services including evaluation, monitoring, and treatment for CRS related conditions on a periodic basis.
Fraud – The intentional deception or misrepresentation made by a person or persons with the knowledge that the deception could result in some unauthorized benefit to him/her or some other person. It includes any act that constitutes fraud under applicable Federal or State law.
Grievance – An expression of dissatisfaction about any matter other than an action. Possible subjects for grievances include, but are not limited to: 1) The quality of care or services provided; and 2) Aspects of interpersonal relationships such as rudeness of a provider or employee or failure to respect the enrollee's rights. Grievances do not include "action(s)" as defined in Arizona Administrative Code Title 9, Chapter 34 (9 A.A.C. 34).
Health Insurance Portability and Accountability Act of 1996 (HIPAA) – A federal law that gives patients greater access to personal medical records and more control over how personally identifiable health information is used. The regulation also addresses the obligations of healthcare providers and health plans to protect health information
Interdisciplinary Team– Physician and non-physician professionals, the recipient, and family members who collaborate in planning, delivering, and evaluating health care services.
Limited English Proficiency (LEP) – A description of an individual's ability to speak and understand the English language when communication is difficult through spoken and written English.
Minor – An individual who is: 1) Under the age of 18 years; 2) Incompetent as determined by a court of competent jurisdiction; or 3) Incapable of giving consent for medical services due to a limitation in the individual's cognitive function as determined by a physician.
Multi-Specialty – The use of more than one specialty physician or dentist in the treatment of a Recipient.
Multi-Specialty, Interdisciplinary Clinic (MSIC) – An established facility where specialists from multiple specialties meet with Recipients and their families for the purpose of providing interdisciplinary services to treat the Recipient's CRS condition.
Notice of Action – Written notification to the Title XIX/XXI recipient/ representative of an action that the CRS Contractor has taken or intends to take.
Notice of Appeal Resolution – Written notification to the recipient/ representative and other parties of the decision made by the CRS Contractor of an appeal.
Notice of Eligibility Determination – Also called Recipient Status Decision. Written notice to the applicant/ representative of the decision of the CRS Program to deny enrollment or disenroll a recipient.
Out of Network – Care provided by health care providers that are not a part of the CRS Contractor's provider network.
Parent Action Council (PAC) – A local, parent-driven council consisting of members including parents of a child who is or has been a CRS recipient, adults, who are or were CRS recipients, and the CRS Contractor. PAC members may also include professionals and members of advocacy groups.
Protected Health Information (PHI) – Under HIPAA, this refers to individually identifiable health information transmitted or maintained in any form.
Provider – A person or entity that subcontracts with a CRS Contractor to provide CRS covered services directly to recipients.
Provider Network – A person or entity who agrees to the terms specified in the contract with the CRS Contractor.
Qualified– An individual meets the conditions, criteria, or requirements for enrollment in the CRS Program.
Resident– An individual who is living in Arizona and can provide proof of residency.
Service Plan – A document that is developed consistent with applicable practice guidelines, which combines the various elements of multiple treatment plans with needed family support services and care coordination activities to provide a map of the steps to be taken for each recipient in achieving treatment and quality of life goals.
Special Health Care Needs – Serious and chronic physical, developmental, or behavioral conditions that require medically necessary health and related services of a type or amount beyond that required by children generally. All CRS recipients are considered to be recipients with special health care needs.
Specialty Physician – A physician who is specially trained in a certain branch of medicine related to specific services or procedures, certain age categories of patients, certain body systems, or certain types of diseases.
Social Work Services – Iinclude: information and referral, support and counseling, screening and assessment, and documentation and coordination of services.
Stop loss insurance – Coverage purchased by employers in order to limit their exposure under Self Insurance medical plans.
TDD – means Telecommunications Device for the Deaf.
Treatment Plan – A written plan of services and therapeutic interventions based on a comprehensive assessment of a recipient's developmental and health status, strengths, and needs that are designed and periodically updated by the interdisciplinary team.
UnitedHealthcare Community Plan – UnitedHealthcare Community Plan is the contracted provider administering the CRS program.
Virtual Clinics – Integrated services provided in community settings through the use of innovative strategies for care coordination such as Telemedicine, integrated medical records and virtual interdisciplinary treatment team meetings.