| (19) Credible allegation of fraud--An allegation of
fraud that has been verified by the state. An allegation is considered
to be credible when HHSC has carefully reviewed all allegations, facts,
and evidence and has verified that the allegation has indicia of reliability.
HHSC acts judiciously on a case-by-case basis.
(20) DADS--The Texas Department of Aging and Disability
Services, its successor, or designee; the state agency responsible
for administering long-term services and support for people who are
aging and people with intellectual and physical disabilities.
(21) Day--A calendar day.
(22) Delivery of a health care item or service--Providing
any item or service to an individual to meet his or her physical,
mental or emotional needs or well-being, whether or not reimbursed
under Medicare, Medicaid, or any federal health care program.
(23) Enrollment--The HHSC process that a provider or
applicant follows to enroll or re-enroll as a provider or enroll a
new practice location.
(24) Enrollment application--Documentation required
by HHSC that an applicant submits to HHSC to enroll or re-enroll as
a provider or to add a practice location. An enrollment application
includes any supplemental forms used to add practice locations for
Medicare-enrolled or limited-risk providers, as determined by HHSC.
(25) Exclusion--The suspension of a provider or any
person from being authorized under the Medicaid program to request
reimbursement of items or services furnished by that specific provider.
(26) Executive Commissioner--The HHSC Executive Commissioner.
(27) False statement or misrepresentation--Any statement
or representation that is inaccurate, incomplete, or untrue.
(28) Federal health care program--Any plan or program
that provides health benefits, whether directly, through insurance,
or otherwise, which is funded directly, in whole or in part, by the
United States government (other than the federal employee health insurance
program under Chapter 89 of Title 5, U.S.C.).
(29) Fraud--Any intentional deception or misrepresentation
made by a person with the knowledge that the deception could result
in some unauthorized benefit to that person or some other person.
The term does not include unintentional technical, clerical, or administrative
errors.
(30) Full investigation--Review and development of
evidence to support an allegation or complaint to resolution through
dismissal, settlement, or formal hearing.
(31) Furnished--Items or services provided or supplied,
directly or indirectly, by any person. This includes items and services
manufactured, distributed, or otherwise provided by persons that do
not directly submit claims to Medicare, Medicaid, or any federal health
care program, but that supply items or services to providers, practitioners,
or suppliers who submit claims to these programs for such items or
services. This term does not include persons that submit claims directly
to these programs for items and services ordered or prescribed by
another person.
(A) Directly--The provision of items and services by
individuals or entities (including items and services provided by
them, but manufactured, ordered, or prescribed by another individual
or entity) who submit claims to Medicare, Medicaid, or any federal
health care program.
(B) Indirectly--The provision of items and services
manufactured, distributed, or otherwise supplied by individuals or
entities who do not directly submit claims to Medicare, Medicaid,
or other federal health care programs, but that provide items and
services to providers, practitioners, or suppliers who submit claims
to these programs for such items and services.
(32) Health information--Any information, whether oral
or recorded in any form or medium, that is created or received by
a health care provider, health plan, public health authority, employer,
life insurer, school or university, or health care clearinghouse,
and that relates to:
(A) the past, present, or future physical or mental
health or condition of an individual;
(B) the provision of health care to an individual;
or
(C) the past, present, or future payment for the provision
of health care to an individual.
(33) HHS--Health and human services. Means:
(A) a health and human services agency under the umbrella
of HHSC, including HHSC;
(B) a program or service provided under the authority
of HHSC, including Medicaid and CHIP; or
(C) a health and human services agency, including those
agencies delineated in Texas Government Code §531.001.
(34) HHSC--The Texas Health and Human Services Commission,
its successor, or designee.
(35) HIPAA--Collectively, the Health Insurance Portability
and Accountability Act of 1996, 42 U.S.C. §§1320d et seq.,
and regulations adopted under that act, as modified by the Health
Information Technology for Economic and Clinical Health Act (HITECH)
(P.L. 111-105), and regulations adopted under that act at 45 C.F.R.
Parts 160 and 164.
(36) Immediate family member--An individual's spouse
(husband or wife); natural or adoptive parent; child or sibling; stepparent,
stepchild, stepbrother or stepsister; father-, mother-, daughter-,
son-, brother- or sister-in-law; grandparent or grandchild; or spouse
of a grandparent or grandchild.
(37) Indirect ownership interest--Any ownership interest
in an entity that has an ownership interest in another entity. The
term includes an ownership interest in any entity that has an indirect
ownership interest in the entity at issue.
(38) Inducement--An attempt to entice or lure an action
on the part of another in exchange for, without limitation, cash in
any amount, entertainment, any item of value, a promise, specific
performance, or other consideration.
(39) Inspector General--The individual appointed to
be the director of the OIG by the Texas Governor in accordance with
Texas Government Code §531.102(a-1).
(40) "Item" or "service" means--
(A) Any item, device, medical supply or service provided
to a patient:
(i) that is listed in an itemized claim for program
payment or a request for payment; or
(ii) for which payment is included in other federal
or state health care reimbursement methods, such as a prospective
payment system; and
(B) In the case of a claim based on costs, any entry
or omission in a cost report, books of account, or other documents
supporting the claim.
(41) Jurisdiction--An issue or matter that the OIG
has authority to investigate and act upon.
(42) Knew or should have known--A person, with respect
to information, knew or should have known when the person had or should
have had actual knowledge of information, acted in deliberate ignorance
of the truth or falsity of the information, or acted in reckless disregard
of the truth or falsity of the information. Proof of a person's specific
intent to commit a program violation is not required in an administrative
proceeding to show that a person acted knowingly.
(43) Managed care plan--A plan under which a person
undertakes to provide, arrange for, pay for, or reimburse, in whole
or in part, the cost of any health care service. A part of the plan
must consist of arranging for or providing health care services as
distinguished from indemnification against the cost of those services
on a prepaid basis through insurance or otherwise. The term does not
include an insurance plan that indemnifies an individual for the cost
of health care services.
(44) Managing employee--An individual, regardless of
the person's title, including a general manager, business manager,
administrator, officer, or director, who exercises operational or
managerial control over the employing entity, or who directly or indirectly
conducts the day-to-day operations of the entity.
(45) MCO--Managed care organization. Has the meaning
described in §353.2 of this title (relating to Definitions) and
for purposes of this chapter includes an MCO's special investigative
unit under Texas Government Code §531.113(a)(1), and any entity
with which the MCO contracts for investigative services under Texas
Government Code §531.113(a)(2).
(46) MCO provider--An association, group, or individual
health care provider furnishing services to MCO members under contract
with an MCO.
(47) Medicaid or Medicaid program--The Texas medical
assistance program established under Texas Human Resources Code Chapter
32 and regulated in part under Title 42 C.F.R. Part 400 or its successor.
(48) Medicaid-related funds--Any funds that:
(A) a provider obtains or has access to by virtue of
participation in Medicaid; or
Cont'd... |
