The following words and terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise:

1. (1) Action - Termination, suspension, or reduction of Medicaid eligibility or covered services by an operating agency or its designee. "Action" includes the denial of Medicaid eligibility and the denial of program eligibility. The term also means determinations by skilled nursing facilities and nursing facilities to transfer or discharge residents and adverse determinations made by an operating agency or its designee with regard to the preadmission screening and annual resident review. "Action" includes a denial of a prior authorization request for covered services affecting an individual. The term also includes the failure of an operating agency or its designee to act upon an individual's request for Medicaid covered services or for an eligibility determination within a reasonable amount of time. "Action" does not include expiration of a time-limited service.
2. (2) Adverse determination - Determination 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.
3. (3) Date of action - The intended date on which a termination, suspension, reduction, transfer, or discharge becomes effective. It also means the date of the determination made by an operating agency with regard to the preadmission screening and resident review.
4. (4) Designee - A contractor of an operating agency authorized to take an action or adverse determination as defined in paragraphs (1) and (2) of this section on behalf of the operating agency.
5. (5) Medicaid eligibility - The eligibility of an individual to receive services under the Texas Medicaid program.
6. (6) Operating agency - A state agency operating part of the Title XIX (Medicaid) program under the Social Security Act and includes the Department of Health, the Department of Human Services, the Rehabilitation Commission, and the Department of Mental Health and Mental Retardation.
7. (7) Prior authorization request - A request for services that are reimbursable only when authorization or approval is obtained before services are rendered. Prior authorized services may be limited in duration, scope, and amount. Services provided beyond those authorized are not reimbursable. If a prior authorization is limited in duration, scope, or amount, a separate request and approval must be obtained for each prior authorized service.
8. (8) Program eligibility - The eligibility of an individual to receive services within a particular Medicaid program.

Source Note:The provisions of this §357.3 adopted to be effective March 31, 1999, 24 TexReg 2293.