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, Health and Safety Code, Chapter 43.
2. (2) Action--Denial, modification, suspension or termination of treatment services or participation rights of an applicant or a recipient of the program.
3. (3) 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.
4. (4) Administrative sanctions--Penalties imposed on a provider who fails to comply with program rules, policies, procedures or standards, which may include recoupment or adjustment of payments, or payment hold.
5. (5) Applicant--A person applying to receive oral health treatment services under the program, but for whom eligibility has not been established.
6. (6) 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.
7. (7) Commissioner--The Commissioner of the Department of State Health Services.
8. (8) Conflict--The proposed modification, suspension or termination of a contract with a provider.
9. (9) Dentist--An individual licensed by the Texas State Board of Dental Examiners to practice dentistry in the State of Texas.
10. (10) Dentally accepted standards--Operating in accordance with the laws relating to the practice of dentistry and the rules of the Texas State Board of Dental Examiners and standards of practice.
11. (11) Department--Department of State Health Services.
12. (12) Eligible individual--An individual who meets the criteria necessary to receive oral health treatment services under the Act and the rules in this chapter.
13. (13) Emergency care--Oral health treatment services for relief of pain and infection, including extractions and basic restorative services to prevent premature loss of teeth.
14. (14) Manual--A compilation of policies, procedures, and instructions prepared by the department's Oral Health Program for the Fee-for-Service Dental Care Program 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 during participation in the program.
15. (15) Non-provider--A dentist or physician licensed to practice under Texas state law but not currently under contract with the department to participate in the program.
16. (16) Oral Health Program (OHP)--The Oral Health Program of the department comprised of central office staff and regional dental teams.
17. (17) Oral health services--Preventive or treatment services affecting the structures of the mouth, including the hard and soft tissues such as teeth, jaws, gums, vestibule, tongue, checks, lips, floor and roof of the mouth, and adjacent masticatory structure, and oral health education and promotion activities.

18. (18) 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 services, 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 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.
19. (19) Physician--An individual licensed by the Texas Medical Board to practice medicine in the State of Texas.
20. (20) Program--The department's Fee-for-Service Dental Care Program administered by the department's OHP, which provides oral health treatment services to eligible individuals.
21. (21) Provider--A person with whom the department contracts to provide oral health treatment services under the Act.
22. (22) Recipient--A person approved as eligible to receive oral health treatment services.
23. (23) State dental director--A Texas licensed dentist who serves as the manager of the OHP, or that person's designee.
24. (24) State fiscal year--The period from September 1 through August 31 of the following year.
25. (25) Support--The contribution of money or services necessary for a person's maintenance, including food, clothing, shelter, transportation, and health care.
26. (26) 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 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.