The following words and terms, when used in this chapter, have
the following meanings unless the context clearly indicates otherwise:
(1) Abuse--A practice by a provider that is inconsistent
with sound fiscal, business, or medical practices and that results
in an unnecessary cost to the Medicaid program; the reimbursement
for services that are not medically necessary or that fail to meet
professionally recognized standards for health care; or a practice
by a recipient that results in an unnecessary cost to the Medicaid
program.
(2) Address of record--
(A) An HHS provider's current mailing or physical address,
including a working fax number, as provided to the appropriate HHS
program's claims administrator or as required by contract, statute,
or regulation; or
(B) a non-HHS provider's last known address as reflected
by the records of the United States Postal Service or the Texas Secretary
of State's records for business organizations, if applicable.
(3) Affiliate; affiliate relationship--A person who:
(A) has a direct or indirect ownership interest (or
any combination thereof) of five percent or more in the person;
(B) is the owner of a whole or part interest in any
mortgage, deed of trust, note or other obligation secured (in whole
or in part) by the entity whose interest is equal to or exceeds five
percent of the value of the property or assets of the person;
(C) is an officer or director of the person, if the
person is a corporation;
(D) is a partner of the person, if the person is organized
as a partnership;
(E) is an agent or consultant of the person;
(F) is a consultant of the person and can control or
be controlled by the person or a third party can control both the
person and the consultant;
(G) is a managing employee of the person, that is,
a person (including a general manager, business manager, administrator
or director) who exercises operational or managerial control over
a person or part thereof, or directly or indirectly conducts the day-to-day
operations of the person or part thereof;
(H) has financial, managerial, or administrative influence
over the operational decisions of a person;
(I) shares any identifying information with another
person, including tax identification numbers, social security numbers,
bank accounts, telephone numbers, business addresses, national provider
numbers, Texas provider numbers, and corporate or franchise names;
or
(J) has a former relationship with another person as
described in subparagraphs (A) - (I) of this definition, but is no
longer described, because of a transfer of ownership or control interest
to an immediate family member or a member of the person's household
of this section within the previous five years if the transfer occurred
after the affiliate received notice of an audit, review, investigation,
or potential adverse action, sanction, board order, or other civil,
criminal, or administrative liability.
(4) Agent--Any person, company, firm, corporation,
employee, independent contractor, or other entity or association legally
acting for or in the place of another person or entity.
(5) Allegation of fraud--Allegation of Medicaid fraud
received by HHSC from any source that has not been verified by the
state, including an allegation based on:
(A) a fraud hotline complaint;
(B) claims data mining;
(C) data analysis processes; or
(D) a pattern identified through provider audits, civil
false claims cases, or law enforcement investigations.
(6) Applicant--An individual or an entity that has
filed an enrollment application to become a provider, re-enroll as
a provider, or enroll a new practice location in a Medicaid program
or the Children's Health Insurance Program as described in subsection
(23) of this section.
(7) At the time of the request--Immediately upon request
and without delay.
(8) Audit--A financial audit, attestation engagement,
performance audit, compliance audit, economy and efficiency audit,
effectiveness audit, special audit, agreed-upon procedure, nonaudit
service, or review conducted by or on behalf of the state or federal
government. An audit may or may not include site visits to the provider's
place of business.
(9) Auditor--The qualified person, persons, or entity
performing the audit on behalf of the state or federal government.
(10) Business day--A day that is not a Saturday, Sunday,
or state legal holiday. In computing a period of business days, the
first day is excluded and the last day is included. If the last day
of any period is a Saturday, Sunday, or state legal holiday, the period
is extended to include the next day that is not a Saturday, Sunday,
or state legal holiday.
(11) C.F.R.--The Code of Federal Regulations.
(12) CHIP--The Texas Children's Health Insurance Program
or its successor, established under Title XXI of the federal Social
Security Act (42 U.S.C. §§1397aa et seq.) and Chapter 62
of the Texas Health and Safety Code.
(13) Claim--
(A) A written or electronic application, request, or
demand for payment by the Medicaid or other HHS program for health
care services or items; or
(B) A submitted request, demand, or representation
that states the income earned or expense incurred by a provider in
providing a product or a service and that is used to determine a rate
of payment under the Medicaid or other HHS program.
(14) Claims administrator--The entity an operating
agency has designated to process and pay Medicaid or HHS program provider
claims.
(15) Closed-end contract--A contract or provider agreement
for a specific period of time. It may include any specific requirements
or provisions deemed necessary by the OIG to ensure the protection
of the program. It must be renewed for the provider to continue to
participate in the Medicaid or other HHS program.
(16) CMS--The Centers for Medicare & Medicaid Services
or its successor. CMS is the federal agency responsible for administering
Medicare and overseeing state administration of Medicaid and CHIP.
(17) Complete Application--A provider enrollment application
that contains all the required information, including:
(A) all questions answered completely, including correct
dates of birth, social security numbers, license numbers, and all
requirements per provider type defined in the Texas Medicaid Provider
Procedures Manual;
(B) IRS Form W-9, if required;
(C) signed and certified provider agreements;
(D) Provider Information Form (PIF-1);
(E) Principal Information Forms (PIF-2) on all persons
required to be disclosed, if required;
(F) full disclosure of all criminal history, including
copies of complete dispositions on all criminal history;
(G) full disclosure of all board or licensing orders,
including documentation of compliance with current board orders;
(H) full disclosure of all corporate compliance agreements,
settlement agreements, state or federal debt, and sanctions;
(I) documentation of an active license that is not
subject to expiration within 30 days of submission of the enrollment
application, if required;
(J) completion of a pre-enrollment site visit by HHSC,
if required, and all required current documentation (e.g., liability
insurance);
(K) documentation of fingerprints of a provider or
any person with a five percent or more direct or indirect ownership
in the provider, if required; and
(L) any additional documentation related to the addition
of a practice location, if required or requested by HHSC.
(18) Conviction or convicted--Means that:
(A) a judgment of conviction has been entered against
an individual or entity by a federal, state, or local court, regardless
of whether:
(i) there is a post-trial motion or an appeal pending;
or
(ii) the judgment of conviction or other record relating
to the criminal conduct has been expunged or otherwise removed;
(B) a federal, state, or local court has made a finding
of guilt against an individual or entity;
(C) a federal, state, or local court has accepted a
plea of guilty or nolo contendere by an individual or entity; or
(D) an individual or entity has entered into participation
in a first offender, deferred adjudication, pre-trial diversion, or
other program or arrangement where judgment of conviction has been
withheld.
Cont'd... |
