10A N.C. Admin. Code 45A.0102

Current through Register Vol. 39, No. 9, November 1, 2024

Section 45A .0102 - DEFINITIONS

The following definitions shall apply throughout this Subchapter:

(1) "Authorization" means agreement by a payment program to pay for a medical or dental service or appliance provided all requirements in this Subchapter are met. An authorization is sent to the provider of service and copy is sent to individual receiving the service.

(2) "Benefits" means the purchase of medical or dental care on a fee-for-service basis. "Benefits" also means the purchase of medical or dental appliances.

(3) "Department" means the Department of Health and Human Services, or its contractor.

"Inpatient services" means medical or dental care administered to a person who has been admitted to a hospital.

(5) "Outpatient services" means medical or dental care administered to a person without admission to a hospital.

(6) "Payment programs" refers to Department program activities involving the purchase of medical or dental care on a fee-for-service basis or the purchase of medical or dental appliances, either through direct payment or through contracts with local health departments, other agencies, or private institutions. Examples of payment programs include:

(a) Early Hearing Detection and Intervention;

(b) HIV Medications Program;

(c) Infant Toddler Program; and

(d) Sickle Cell Program.

(7) "Provider" means a person or entity who administers medical or dental care or furnishes medical or dental appliances under any of the payment programs.

(8) Third Party Payor for the purposes of this Subchapter means any person or entity that is or may be indirectly liable for the cost of services or appliances furnished to a patient. Third party payors include the following:

(a) School services, including physical or occupational therapy, speech and language pathology and audiology services, and nursing services for special needs children;

(b) Medicaid;

(c) Medicare, Part A and Part B;

(d) Insurance;

(e) Social Services;

(f) Worker's compensation;

(h) TRICARE, formerly Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); and

(i) Head Start programs.

10A N.C. Admin. Code 45A .0102

Authority G.S. 130A-5(3); 130A-124; 130A-127; 130A-129; 130A-205;
Eff. July 1, 1981;
Amended Eff. July 1, 1986; January 1, 1982;
Transferred and Recodified from 10 NCAC 04C .0102 Eff. April 4, 1990;
Amended Eff. January 1, 2014; April 1, 1999; January 1, 1996; December 1, 1990;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 13, 2015.

Authority G.S. 130A-5(3); 130A-124; 130A-127; 130A-129; 130A-205; Eff. July 1, 1981;
Amended Eff. July 1, 1986; January 1, 1982;
Transferred and Recodified from 10 NCAC 04C .0102 Eff. April 4, 1990;
Amended Eff. January 1, 2014; April 1, 1999; January 1, 1996; December 1, 1990.