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

1. (1) Action--Denial, modification, suspension, or termination of fee-for-service (FFS) oral health treatment benefits or participation rights of an applicant or a recipient.
2. (2) Administrative review--A secondary level of review available to applicants, recipients, and providers who want to resolve a conflict, or appeal an administrative sanction or a denied claim.
3. (3) Administrative sanctions--Penalties imposed on a provider who fails to comply with rules, policies, procedures, or standards, which may include recoupment or adjustment of payments, payment hold, or termination of the provider's contract.
4. (4) Applicant--A person applying to receive FFS oral health treatment benefits, but for whom eligibility has not been established.
5. (5) Business day--Normal department operating hours from 8:00 a.m. - 5:00 p.m., Monday through Friday, with the exception of state and federal holidays.
6. (6) Conflict--The proposed modification, suspension, or termination of a contract with a provider.
7. (7) Dentist--An individual licensed by the Texas State Board of Dental Examiners (TSBDE) to practice dentistry in the State of Texas.
8. (8) Dentally accepted standards--Operating in accordance with the laws relating to the practice of dentistry, the rules of the TSBDE, and standards of practice.
9. (9) Eligible individual--An individual who meets the criteria necessary to receive oral health treatment benefits under the Act and the rules in this chapter.
10. (10) Emergency care--Oral health treatment services for relief of pain and infection, including extractions and basic restorative services to prevent premature loss of teeth.
11. (11) FFS--The department's fee-for-service oral health treatment benefits, administered by the department's Oral Health Program.
12. (12) FFS oral health treatment benefits manual (manual)--A compilation of policies, procedures, and instructions prepared by the department's Oral Health Program for FFS oral health treatment benefits, to be used by providers of oral health treatment services. Participating providers will receive a copy of the manual and any updates, changes, and amendments, and must comply with its requirements.
13. (13) Non-provider--A dentist or physician licensed to practice under Texas state law but not currently under contract with the department to provide oral health treatment benefits.
14. (14) Oral Health Program--A program comprised of central office staff and regional dental teams.
15. (15) Oral health treatment benefits--Preventive or treatment services affecting the structures of the mouth, including the hard and soft tissues such as teeth, jaws, gums, vestibule, tongue, cheeks, lips, floor and roof of the mouth, and adjacent masticatory structure.

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

    1. (A) an insurance policy, group oral health plan, or prepaid oral care plan;
    2. (B) 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. (C) the Veteran's Administration;
    4. (D) the Civilian Health and Medical Program of the Uniformed Services;
    5. (E) worker's compensation or any other compulsory employer's insurance program;
    6. (F) a public program created by federal law, state law, or the ordinances or rules of a municipality or political subdivision of the state; or
    7. (G) a cause of action for dental or oral health treatment benefits expenses or a settlement or judgment based upon the cause of action, if the expenses are related to the need for treatment benefits provided under the Act.
17. (17) Physician--An individual licensed by the Texas Medical Board to practice medicine in the State of Texas.
18. (18) Provider--A person with whom the department contracts to provide oral health treatment services under the Act.
19. (19) Recipient--A person approved as eligible to receive oral health treatment benefits.
20. (20) State dental director--A Texas licensed dentist who serves as the manager of the Oral Health Program, or that person's designee.
21. (21) State fiscal year--The period from September 1 through August 31 of the following year.
22. (22) Support--The contribution of money or services necessary for a person's maintenance, including food, clothing, shelter, transportation, and health care.
23. (23) Third-party nominator--A person aware of an applicant's economic condition who refers the applicant to the Oral Health Program for oral health treatment benefits. Third-party nominators include school administrators, school nurses, social workers, city or county officials, public health clinics, community health centers, dentists, physicians, hospitals, or any other source acceptable to the Executive Commissioner of the Health and Human Services Commission.

Source Note:The provisions of this §49.2 adopted to be effective October 16, 2008, 33 TexReg 8522; amended to be effective July 22, 2013, 38 TexReg 4634.