Definitions

POLICY: The following definitions are applicable to this policy. For any others not described below, refer to the applicable payer's policy definitions, including the Florida Medicaid Definitions Policy where Florida Medicaid is the funding source.

• Claim Reimbursement Policy: A policy document found in Division 59G, F.A.C. that provides instructions on how to bill for services.
• Coverage and Limitations Handbook or Coverage Policy: A policy document found in Rule 59G, F.A.C., that contains coverage information about an applicable service benefit, including Medicaid services when applicable.
• General Policies: A policy document found in Rule 59G, F.A.C., or other applicable payer guidance that outlines coverage criteria and service limitations.
• Lead Analyst: Practitioner responsible for the implementation of behavior analysis services, including the completion and review of behavior assessments, reassessments, behavior plans, and behavior plan reviews.
• Medically Necessary/Medical Necessity: Meet the following conditions:
  • Necessary to protect life, prevent significant illness or significant disability, or to alleviate severe pain.
  • Individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient's needs.
  • Consistent with generally accepted professional medical standards as determined by the applicable payer and not experimental or investigational.
  • Reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide.
  • Furnished in a manner not primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider.
• Provider: Any entity, facility, person, or group enrolled with AHCA or credentialed with an applicable payer to furnish services in accordance with the applicable provider agreement.
• Recipient: An individual covered under an applicable payer or funding source, including Florida Medicaid and its managed care plan enrollees, Medicare, commercial insurance, or another payer.