“Appropriate and medically necessary” means, regarding drug prescribing, dispensing, and patient usage, that it is in conformity with the criteria and standards developed in accordance with this part.
Certified program: means a nursing care facility program with Medicaid certification. See Utah Code 26B-3-301
Criteria: means those predetermined and explicitly accepted elements used to measure drug use on an ongoing basis in order to determine if the use is appropriate, medically necessary, and not likely to result in adverse medical outcomes. See Utah Code 26B-3-301
Division: means the Division of Integrated Healthcare within the department, established under Section 26B-3-102. See Utah Code 26B-3-101
Intellectual disability: means a significant, subaverage general intellectual functioning that:Utah Code 68-3-12.5
Medicaid certification: means the right of a nursing care facility, as a provider of a nursing care facility program, to receive Medicaid reimbursement for a specified number of beds within the facility. See Utah Code 26B-3-301
Medicaid program: means the state program for medical assistance for persons who are eligible under the state plan adopted pursuant to Title XIX of the federal Social Security Act. See Utah Code 26B-3-101
Nursing care facility: means the following facilities licensed by the department under 2:
(i)
skilled nursing facilities;
(ii)
intermediate care facilities; and
(iii)
an intermediate care facility for people with an intellectual disability. See Utah Code 26B-3-301
Nursing care facility program: means the personnel, licenses, services, contracts, and all other requirements that shall be met for a nursing care facility to be eligible for Medicaid certification under this part and division rule. See Utah Code 26B-3-301
Recipient: means a person who has received medical assistance under the Medicaid program. See Utah Code 26B-3-101
Rural county: means a county with a population of less than 50,000, as determined by:
(a)
the most recent official census or census estimate of the United States Bureau of the Census; or
(b)
the most recent population estimate for the county from the Utah Population Committee, if a population figure for the county is not available under Subsection (20)(a). See Utah Code 26B-3-301
Standards: means the acceptable range of deviation from the criteria that reflects local medical practice and that is tested on the Medicaid recipient database. See Utah Code 26B-3-301
State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
United States: includes each state, district, and territory of the United States of America. See Utah Code 68-3-12.5
(2)
“Board” means the Drug Utilization Review Board created in Section 26B-3-302.
(3)
“Certified program” means a nursing care facility program with Medicaid certification.
(4)
“Compendia” means resources widely accepted by the medical profession in the efficacious use of drugs, including “American Hospital Formulary Service Drug Information,” “U.S. Pharmacopeia – Drug Information,” “A.M.A. Drug Evaluations,” peer-reviewed medical literature, and information provided by manufacturers of drug products.
(5)
“Counseling” means the activities conducted by a pharmacist to inform Medicaid recipients about the proper use of drugs, as required by the board under this part.
(6)
“Criteria” means those predetermined and explicitly accepted elements used to measure drug use on an ongoing basis in order to determine if the use is appropriate, medically necessary, and not likely to result in adverse medical outcomes.
(7)
“Drug-disease contraindications” means that the therapeutic effect of a drug is adversely altered by the presence of another disease condition.
(8)
“Drug-interactions” means that two or more drugs taken by a recipient lead to clinically significant toxicity that is characteristic of one or any of the drugs present, or that leads to interference with the effectiveness of one or any of the drugs.
(9)
“Drug Utilization Review” or “DUR” means the program designed to measure and assess, on a retrospective and prospective basis, the proper use of outpatient drugs in the Medicaid program.
(10)
“Intervention” means a form of communication utilized by the board with a prescriber or pharmacist to inform about or influence prescribing or dispensing practices.
(11)
“Medicaid certification” means the right of a nursing care facility, as a provider of a nursing care facility program, to receive Medicaid reimbursement for a specified number of beds within the facility.
(12)
(a)
“Nursing care facility” means the following facilities licensed by the department under 2:
(i)
skilled nursing facilities;
(ii)
intermediate care facilities; and
(iii)
an intermediate care facility for people with an intellectual disability.
(b)
“Nursing care facility” does not mean a critical access hospital that meets the criteria of 42 U.S.C. § 1395i-4(c)(2) (1998).
(13)
“Nursing care facility program” means the personnel, licenses, services, contracts, and all other requirements that shall be met for a nursing care facility to be eligible for Medicaid certification under this part and division rule.
(14)
“Overutilization” or “underutilization” means the use of a drug in such quantities that the desired therapeutic goal is not achieved.
“Physical facility” means the buildings or other physical structures where a nursing care facility program is operated.
(17)
“Physician” means a person licensed in this state to practice medicine and surgery under Section 58-67-301 or osteopathic medicine under Section 58-68-301.
(18)
“Prospective DUR” means that part of the drug utilization review program that occurs before a drug is dispensed, and that is designed to screen for potential drug therapy problems based on explicit and predetermined criteria and standards.
(19)
“Retrospective DUR” means that part of the drug utilization review program that assesses or measures drug use based on an historical review of drug use data against predetermined and explicit criteria and standards, on an ongoing basis with professional input.
(20)
“Rural county” means a county with a population of less than 50,000, as determined by:
(a)
the most recent official census or census estimate of the United States Bureau of the Census; or
(b)
the most recent population estimate for the county from the Utah Population Committee, if a population figure for the county is not available under Subsection (20)(a).
(21)
“Service area” means the boundaries of the distinct geographic area served by a certified program as determined by the division in accordance with this part and division rule.
(22)
“Standards” means the acceptable range of deviation from the criteria that reflects local medical practice and that is tested on the Medicaid recipient database.
(23)
“SURS” means the Surveillance Utilization Review System of the Medicaid program.
(24)
“Therapeutic appropriateness” means drug prescribing and dispensing based on rational drug therapy that is consistent with criteria and standards.
(25)
“Therapeutic duplication” means prescribing and dispensing the same drug or two or more drugs from the same therapeutic class where periods of drug administration overlap and where that practice is not medically indicated.
(26)
“Urban county” means a county that is not a rural county.
Renumbered and Amended by Chapter 306, 2023 General Session
