Medicaid Eligible. Individual who has been determined to be eligible for Medicaid and who has been issued a Medicaid card. Medicaid eligibility is linked to certain coverages, services and benefits defined in the state plan for medical assistance. Because of the link between eligibility and benefits, Medicaid eligible individuals are also referred to in this agreement as "beneficiaries."
Medicaid Eligible. An individual eligible to receive services under the Medicaid Program but not necessarily enrolled in the Medicaid Program.
Medicaid Eligible. An individual eligible to receive services under Medicaid, who is eligible, on this basis, to enroll in the GHP Program. Medicaid Fraud Control Unit (“MFCU”): The Unit created by the Puerto Rico Department of Justice under Administrative Order 2018-002 to investigate and prosecute Medicaid Provider Fraud as well as patient abuse and neglect in health care facilities, as defined in Section 1903(q) of the Social Security Act, found at 42 USC 1396b(q). Medicaid Management Information System (“MMIS”): Computerized system used for the processing, collecting, analyzing, and reporting of Information needed to support Medicaid and CHIP functions. The MMIS consists of all required subsystems as specified in the State Medicaid Manual. Medical Advice Service: The twenty-four (24) hour emergency medical advice toll-free phone line operated by the Contractor through its GHP Service Line service, described in Section 6.8 of the ASES Contract.
Medicaid Eligible. An individual eligible to receive services under Medicaid, who is eligible, on this basis, to enroll in the GHP Program. Medicaid Fraud Control Unit (“MFCU”): The Agency which investigates and prosecutes Medicaid Provider fraud as well as patient abuse and neglect in health care facilities, as defined in Section 1903(q) of the Social Security Act, found at 42 USC 1396b(q). Medicaid Management Information System (“MMIS”): Computerized system used for the processing, collecting, analyzing, and reporting of Information needed to support Medicaid and CHIP functions. The MMIS consists of all required subsystems as specified in the State Medicaid Manual. Medical Advice Service: The twenty-four (24) hour emergency medical advice toll-free phone line operated by the Contractor through its GHP Service Line service, described in Section 6.8 of this Contract.
Medicaid Eligible. An individual eligible to receive services under Medicaid, who is eligible, on this basis, to enroll in the GHP Program. Medicaid Fraud Control Unit (“MFCU”): The Unit created by the Puerto Rico Department of Justice under Administrative Order 2018-002 to investigate and prosecute Medicaid Provider Fraud as well as patient abuse and neglect in health care facilities, as defined in Section 1903(q) of the Social Security Act, found at 42 USC 1396b(q). Medicaid Management Information System (“MMIS”): Computerized system used for the processing, collecting, analyzing, and reporting of Information needed to support Medicaid and CHIP functions. The MMIS consists of all required subsystems as specified in the State Medicaid Manual. Medical Necessity or Medically Necessary: Based on generally accepted medical practices specific to the medical or Behavioral Health condition of the Enrollee at the time of treatment, Medically Necessary Services are those that relate to (i) the prevention, diagnosis, and treatment of health impairments; (ii) the ability to achieve age-appropriate growth and development; or (iii) the ability to attain, maintain, or regain functional capacity., and are:
