The following words and terms, when used in the sections under
this subchapter, shall have the following meanings, unless the context
clearly indicates otherwise.
(1) Abuse--Practices that are inconsistent with sound
fiscal, business, or medical practices and that result in unnecessary
program cost or in reimbursement for services that are not medically
necessary, do not meet professionally recognized standards for health
care, or do not meet standards required by contract, statute, regulation,
previously sent interpretations of any of the items listed, or authorized
governmental explanations of any of the foregoing.
(2) Conflicting--Incompatible, unsuitable for use together
because of undesirable chemical or physiological effects. For example,
the recipient may receive drugs and/or health care services which
may be inadvisable in the presence of certain medical conditions or
which conflict with the care ordered by another provider.
(3) Contraindicated--Condition or factor that indicates
the inadvisability of a medical treatment or procedure.
(4) Designated Provider--A provider enrolled in the
Texas Medicaid program that is not on payment review status; under
administrative action, sanction, or investigation for failure to comply
with Medicaid rules or acceptable Medicaid practices; or under sanction
or inactive or other limited administrative status by a state licensing
board or other regulatory entity. The designated provider oversees
the Medicaid benefits or services provided to a recipient in lock-in
status. A designated provider includes:
(A) a primary health care provider who provides and/or
directs all medically necessary health care benefits or services for
which the recipient is eligible. The primary health care provider
may include a physician, physician group, dentist, dental home, advanced
practice nurse, physician assistant, outpatient clinic, Rural Health
Clinic, or Federally Qualified Health Center; or
(B) a pharmacy that monitors medications prescribed
to a recipient in lock-in status for contraindicative, conflicting,
duplicative, or excessive use and that ensures the recipient's use
does not represent abuse, misuse, or fraud.
(5) Emergency medical condition--A medical condition
(including emergency labor and delivery) manifesting itself by acute
symptoms of sufficient severity (including severe pain), such that
a prudent layperson, who possesses an average knowledge of health
and medicine, could reasonably expect the absence of immediate medical
care could result in:
(A) placing the patient's health in serious jeopardy;
(B) serious impairment to bodily functions;
(C) serious dysfunction of any bodily organ or part;
(D) serious disfigurement; or
(E) serious jeopardy to the health of the fetus of
a pregnant Medicaid recipient.
(6) Emergency services--Covered inpatient and outpatient
services that are furnished by a provider who is qualified to furnish
such services under a Medicaid provider agreement and are services
which are needed to evaluate or stabilize an emergency medical condition.
(7) Excessive Use or Overuse--Exceeding what is usual,
medically necessary or customary use of Medicaid services and benefits.
Also defined as, but not limited to, the following:
(A) receipt of Medicaid benefits or services from one
or multiple providers of service in an amount, duration, or scope
in excess of which would reasonably be expected to result in a medical
or health benefit to the patient; or
(B) use exceeding the standards and criteria for utilization
of outpatient drugs or products, as listed in the compendia and peer
reviewed medical literature and/or criteria and standards approved
by the Texas Medicaid Drug Utilization Review Board.
(8) Fraud--Any act that constitutes fraud under applicable
federal or state law, including 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.
Fraud may include any acts prohibited by the Texas Human Resources
Code, Chapter 36, or Texas Penal Code, Chapter 35A. Fraudulent activities
include, but are not limited to:
(A) lending or altering a Medicaid card for the purpose
of obtaining Medicaid benefits or services for which a person is not
legitimately entitled;
(B) falsely representing medical coverage;
(C) using the Medicaid Identification card of another
or altering or duplicating Medicaid identification;
(D) furnishing incorrect eligibility or false information
to a vendor to obtain treatment;
(E) possessing blank or forged prescription pads;
(F) forging, duplicating or altering a prescription;
(G) assisting providers in rendering services or defrauding
the Medicaid program; or
(H) selling or trading, or attempting to sell or trade,
drugs, products, or supplies acquired independently or through Medicaid
that results in duplicative services.
(9) Lock-in--An action taken by the Health and Human
Services Commission (HHSC) restricting a Medicaid recipient to a designated
pharmacy or health care provider.
(10) Lock-in period--The effective time period of a
lock-in measured in cumulative eligibility time frames of 36 months,
60 months, or lifetime. Eligibility time frames may or may not be
contiguous.
(11) Misuse--To use incorrectly, misapply, or illegally
use Medicaid benefits or services. To seek or obtain medical services
from a number of like providers and in quantities that exceed the
levels considered medically necessary by current medical practices,
standards and policies.
(12) Recipient--Any individual who is deemed eligible
to receive Medicaid benefits and services under the Texas Medicaid
Program.
(13) Referrals--Complaint information regarding recipient
use of Medicaid benefits or services supplied to HHSC for lock-in
review. Sources may include, but are not limited to, providers, state
agencies, law enforcement officials, Medicaid managed care organizations,
or members of the general public. HHSC may make referrals to other
state agencies and/or Medicaid managed care plans.
(14) Waste--Practices that a reasonably prudent person
would deem careless or that would allow inefficient use of resources,
items, or services.
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| Source Note: The provisions of this §354.2401 adopted to be effective April 2, 2000, 25 TexReg 2817; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4563; amended to be effective April 6, 2003, 28 TexReg 2738; amended to be effective April 2, 2013, 38 TexReg 2095 |
