44:06:01:00. Definitions. Terms used in this chapter
mean:
(1) "Care coordination
services," services to promote the effective and efficient organization
and utilization of resources to ensure access to necessary comprehensive
services for children with chronic medical conditions and their families;
(2) "Chronic medical
condition," condition has existed or is expected to exist for two years or
more, requires evaluation, consultation and medical treatment, and is a
coverable condition under the CSHS program as listed in § 44:06:06:01;
(3) "Client," an
individual who is determined by CSHS to be eligible for and receiving services;
(4) "Consultation,"
the medical examination and testing by a specialist needed to determine the
cause of and possible treatment for a suspected or known chronic medical
condition;
(5) "Copay," the
obligation of the family or legal guardian for either partial or full payment
of the medical cost after submission of the bill to a health insurance plan;
(6) "Cost share,"
a family's percentage of financial participation in the cost of CSHS authorized
services determined by family size and income;
(7) "CSHS,"
children's special health services;
(8) "Deductible,"
the specified amount that must be met in medical costs and paid by the family
or policy holder before a health insurance plan will pay;
(9) "Department,"
the South Dakota Department of Health;
(10) "Diagnostic
services," use of scientific medical methods to establish the cause and
nature of a person's illness or chronic medical condition;
(11) "Financial
assistance," determined amount paid to a provider by CSHS on a client's
behalf;
(12) "Individual case
review," the process whereby a team of individuals from the department
reviews a request to consider an individual's medical eligibility or treatment;
(13) "Participating
provider," a provider who has a current, signed
participating provider agreement with CSHS;
(14) "Primary care
physician," the physician to whom a family or individual goes for
management of care for acute illness and ongoing health needs;
(15) "Secretary,"
the South Dakota secretary of health or the secretary's designee;
(16) "Third-party
resource," a public or private agency or entity which is or may be liable
to pay all or part of the medical costs of an applicant or client, including
private insurance, Civilian Health and Medical Program Uniformed Services,
Medicaid, Medicare, Indian Health Services, and other sources of funds
available to the applicant or client for medical care;
(17) "Treatment,"
medical or surgical intervention, or both, to alleviate a chronic medical
condition; and
(18) "Usual and
customary charge," the individual provider's normal charge to the general
public for a specific service on the date the service was provided.
Source:
20 SDR 91, effective December 19, 1993; 23 SDR 91, effective December 9, 1996;
30 SDR 198, effective June 23, 2004; 33 SDR 106, effective December 26, 2006.
General
Authority: SDCL 34-1-21.
Law
Implemented: SDCL 34-1-21.
