The following words and terms, where used in these sections, shall have the following meanings, unless the context clearly indicates otherwise.

1. (1) Act--The Texas Oral Health Improvement Act, Texas Health and Safety Code, Chapter 43.
2. (2) Action--Denial, modification, suspension or termination of program benefits or participation rights of an applicant or a recipient of the program.
3. (3) Administrative review--A secondary level of review available to a provider appealing a denied claim.
4. (4) Administrative sanctions--Penalties imposed on a provider who fails to comply with program rules, procedures and standards. Administrative sanctions include, but are not limited to, recoupment of payments, modification, suspension or exclusion of a provider from the program.
5. (5) Applicant--A person applying for the program services, but for whom eligibility has not been established.
6. (6) Approval date--The date a submitted program voucher is approved for payment.
7. (7) Approved provider--An active, participating provider in the program.
8. (8) Board--The Texas Board of Health.
9. (9) Commissioner--The commissioner of health of the Texas Department of Health.
10. (10) Conflict--The proposed modification, suspension or termination of a contract with an approved provider.
11. (11) Dentist--An individual licensed by the Texas State Board of Dental Examiners to practice dentistry in the State of Texas.
12. (12) Dentally accepted standards--Operating in accordance with the laws relating to the practice of dentistry and the rules of the State Board of Dental Examiners and normal standards of practice.
13. (13) Department--The Texas Department of Health.
14. (14) Division--The Division of Oral Health of the Texas Department of Health.
15. (15) Eligible individual--An individual who meets the criteria necessary to receive oral health services under the Act.
16. (16) Emergency care--Treatment for relief of pain and infection, including extractions and basic restorative services to prevent premature loss of teeth.
17. (17) Nonapproved provider--A medical or dental provider authorized to practice under state law but not currently participating in the program.
18. (18) Oral health services--Preventive or treatment services affecting the structures of the mouth, including the hard and soft tissues such as teeth and jaws, gums, vestibule, tongue, cheeks, lips, floor, roof of the mouth, and adjacent masticatory structures, and oral health education and promotion activities.

19. (19) Other benefit--A benefit to which an individual is entitled, other than a benefit provided under the Act, for the payment of the costs of oral health treatment services, including:

    1. (A) benefits available from:

       1. (i) an insurance policy, group oral health plan, or prepaid oral care plan;
       2. (ii) Title XVIII or Title XIX of the Social Security Act, as amended (42 U.S.C. §1395 et seq. and 42 U.S.C. §1396 et seq.);
       3. (iii) the Veteran's Administration;
       4. (iv) the Civilian Health and Medical Program of the Uniformed Services; or
       5. (v) worker's compensation or any other compulsory employer's insurance program;
    2. (B) a public program created by federal law, state law, or the ordinances or rules of a municipality or political subdivision of the state; or
    3. (C) benefits available to an individual applying for or receiving treatment services from the department arising out of a cause of action for dental or oral health treatment services expenses or a settlement or judgment based upon the cause of action, if the expenses are related to the need for treatment services provided under the Act.
20. (20) Physician--An individual licensed by the Texas State Board of Medical Examiners to practice medicine in the State of Texas.
21. (21) Program--The State Fee for Service Dental Care Program administered by the Division of Oral Health which provides oral health services to eligible individuals.
22. (22) Provider--A person who, through a contract with the department, furnishes oral health treatment services which are purchased by the department for the purpose of the Act.
23. (23) Recipient--Any person currently eligible to receive program benefits.
24. (24) Regional dental director--The dental program director for a public health region of the department.
25. (25) Regional director--The chief authority and medical director for a public health region of the department.
26. (26) State Fee for Service Dental Care Program Manual for Providers of Services--A manual prepared by the Division of Oral Health that sets out the program's policies and procedures and includes program rules. Participating providers will receive a copy of this manual and are expected to abide by its provisions during participation in the program.
27. (27) State dental director-The dental program director for the State of Texas.
28. (28) State fiscal year--The period from September 1 to August 31 of the following year.
29. (29) Third-party nominator--A person aware of an applicant's economic condition who refers the applicant to the program for services. Third-party nominators include school administrators, school nurses, social workers, city or county officials, public health clinics, community health centers, dentists, physicians, or hospitals or any other source acceptable to the board.
30. (30) Workday--Normal department operating hours from 8:00 a.m. - 5:00 p.m. Monday through Friday with the exception of state holidays.

Source Note:The provisions of this §49.2 adopted to be effective September 9, 1986, 11 TexReg 3793; amended to be effective March 23, 2003, 28 TexReg 2327.