1. (a) “Acute care” means those services provided to recipients, other than swing bed patients, in a hospital.
2. (b) “Budget neutrality factors” means adjustments applied to rate-setting methodology to reduce spending growth.
3. (c) “Centers for Medicare and Medicaid Services (CMS)” means the division of the federal Department of Health and Human Services that administers medicare, medicaid, the children’s health insurance program, and the health insurance marketplace.
4. (d) “Day outlier” means those cases for which the actual length of stay exceeds the trim point per diagnosis related group.
5. (e) “Department” means the New Hampshire (NH) department of health and human services.
6. (f) “Diagnosis related group (DRG)” means the taxonomy of diagnoses as classified in the medicare DRG classification system which groups hospital inpatient cases according to factors such as principal diagnosis, age, and sex, and assigns a relative weight which represents hospital resource use associated with treatment for the diagnosis, pursuant to 42 CFR 412.60.
7. (g) “Generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, or the recommendations of physician specialists practicing in relevant clinical areas or of various physician specialty societies.
8. (h) “Hospital” means any facility providing acute care services, to include acute care rehabilitation services, not operating as a psychiatric hospital or an institution for mental diseases and which provides the inpatient hospital services defined in 42 CFR 440.10.
9. (i) “In-state hospital” means a hospital which is located within the physical boundaries of NH.
10. (j) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

11. (k) “Medically necessary” means:

    1. (1) For individuals under age 21, reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent the worsening of conditions that endanger life, cause pain, result in illness or infirmity, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction, and no other equally effective course of treatment is available or suitable for the early and periodic screening, diagnosis, and treatment services (EPSDT) recipient requesting a medically necessary service; and

    2. (2) For individuals age 21 and over, health care services that a licensed health care provider, exercising prudent clinical judgment, would provide, in accordance with generally accepted standards of medical practice, to a recipient for the purpose of evaluating, diagnosing, preventing, or treating an acute or chronic illness, injury, disease, or its symptoms, and that are:

       1. a. Clinically appropriate in extent, site, and duration, and consistent with the established diagnosis or treatment of the recipient’s illness, injury, disease, or its symptoms;
       2. b. Not primarily for the convenience of the recipient or the recipient’s family, caregiver, or health care provider;
       3. c. No more costly than other items or services which would produce equivalent diagnostic, therapeutic, or treatment results as related to the recipient’s illness, injury, disease, or its symptoms; and
       4. d. Not experimental, investigative, cosmetic, or duplicative in nature.
12. (l) “Observation services” means services furnished by a hospital on the hospital’s premises, including the use of a bed and periodic monitoring by a hospital’s nursing or other staff, which are reasonable and necessary to evaluate an outpatient’s condition or determine the need for a possible admission to the hospital as an inpatient.
13. (m) “Out-of-state hospital” means a hospital located outside of NH.
14. (n) “Recipient” means an individual who is eligible for and receiving medical assistance under the medicaid program.
15. (o) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in NH by the department under the medicaid program.
16. (p) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in NH by the department under the medicaid program.

Source. (See Revision Note at chapter heading He-W 500); ss by #5897, eff 9-19-94; amd by #6548, eff 7-26-97; ss by #7399, eff 11-2-00, EXPIRED: 11-2-08 New. #9324, eff 11-21-08; amd by #10139, eff 7-1-12; ss by #12103, eff 2-9-17; amd by #12818, eff 7-1-19; ss by #14384, eff 9-20-25, EXPIRES: 9-20-35