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Virginia Administrative Code
Title 12. Health
Agency 30. Department Of Medical Assistance Services
Chapter 100. State Programs
10/22/2021

12VAC30-100-70. Definitions.

The following words and terms, when used in this part, shall have the following meaning unless the context clearly indicates otherwise:

"Allocation process" means the process described in § 32.1-345 B of the Code of Virginia, which is used annually to allocate funds appropriated by the General Assembly for this program to counties and cities of the Commonwealth.

"Board of Medical Assistance Services" or "BMAS" means that board established by § 32.1-324 et seq. of the Code of Virginia.

"Bona fide resident" means an individual who has been determined by the local department of social services to be residing in the city or county where making application at the time of or immediately prior to medical treatment with the intent of remaining permanently in that locality and who did not establish residency for the purposes of obtaining benefits.

"Covered ambulatory surgical center services" means those services which are provided by any distinct licensed and certified entity, established by 42 CFR 416.2, that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization, which do not exceed in amount, duration, and scope those available to recipients of medical assistance services as provided in the State Plan for Medical Assistance established by Chapter 10 (§ 32.1-323 et seq.) of Title 32.1 of the Code of Virginia; and which are rendered by providers who have signed agreements to participate in the SLH program and who are enrolled providers in the MAP.

"Covered inpatient services" means inpatient services that do not exceed in amount, duration, and scope those available to recipients of medical assistance services as provided in the State Plan for Medical Assistance established by Chapter 10 (§ 32.1-323 et seq.) of Title 32.1 of the Code of Virginia and that are rendered by providers who have signed agreements to participate in the SLH program and who are enrolled providers in the MAP.

"Covered local public health services" means services provided by local health departments that do not exceed in amount, duration and scope those available to recipients of medical assistance services as provided in the State Plan for Medical Assistance established by Chapter 10 of Title 32.1 of the Code of Virginia and that are rendered by providers who have signed agreements to participate in the SLH program and who are enrolled providers in the MAP.

"Covered outpatient services" means outpatient services, as performed in an outpatient hospital setting, that do not exceed in amount, duration and scope those available to recipients of medical assistance services as provided in the State Plan for Medical Assistance established by Chapter 10 of Title 32.1 of the Code of Virginia and that are rendered by providers who have signed agreements to participate in the SLH program and who are enrolled providers in the MAP.

"Claim" means a request for payment for services rendered.

"Department" or "DMAS" means the Department of Medical Assistance Services established by § 32.1-323 of the Code of Virginia.

"Director" means the Director of the Department of Medical Assistance Services established by § 32.1-323 of the Code of Virginia.

"DRG" means diagnostic related group of codes to define the severity or intensity of illness.

"Enrolled provider" or "providers" means inpatient or outpatient hospitals, free-standing ambulatory surgical centers and local public health departments which have signed agreements to participate in the SLH program and are enrolled providers in the MAP.

"Indigent person" means a person who is a bona fide resident of the county or city, whether gainfully employed or not and who, either by himself or by those upon whom he is dependent, is unable to pay for required hospitalization or treatment. Residence shall not be established for the purpose of obtaining the benefits of this program. Aliens illegally living in the United States and migrant workers shall not be considered bona fide residents of the county or city for purposes of the SLH program.

"Locality" means any city or county which is required by law to participate in the SLH program.

"MAP" or "Medicaid" means the Medical Assistance Program as administered by the Department of Medical Assistance Services.

"Medical emergency" means that a delay in obtaining treatment may cause death or serious impairment of the health of the patient. See 42 CFR 440.170(e).

"Net countable income" means the value of income using the current budget methodology of the Virginia Aid to Families with Dependent Children Program.

"Net countable resources" means the countable value of an applicant's resources using the current budget methodology of the Virginia Aid to Families with Dependent Children Program.

"Payable claim" means a claim for a covered service rendered to an eligible individual with a date of service in the current SLH payment year provided that the claim is submitted for payment before the last payment processing cycle in June and provided there are funds available in the allocation for the locality of residence of the eligible individual.

"SLH payment year" means a year beginning May 1 of any year and ending April 30 of the following year.

"SLH program" means the State/Local Hospitalization Program.

"State Plan" means the State Plan for Medical Assistance for the Commonwealth.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-05-1000.0000 § 1.1, eff. May 1, 1994; amended Virginia Register Volume 12, Issue 18, eff. July 1, 1996.

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