42 CFR § 431.958 - Definitions and use of terms.
Adjudication date means either the date on which money was obligated to pay a claim or the date the decision was made to deny a claim.
Children's Health Insurance Program (CHIP) means the program authorized and funded under Title XXI of the Act.
Federally Facilitated Exchange (FFE) means the health insurance exchange established by the Federal government with responsibilities that include making Medicaid and CHIP determinations for states that delegate authority to the FFE.
Finding means errors and/or deficiencies identified through the medical, data processing, and eligibility reviews.
Improper payment means any payment that should not have been made or that was made in an incorrect amount (including overpayments and underpayments) under statutory, contractual, administrative, or other legally applicable requirements; and includes any payment to an ineligible beneficiary, any duplicate payment, any payment for services not received, any payment incorrectly denied, and any payment that does not account for credits or applicable discounts.
Improper payment rate means an annual estimate of improper payments made under Medicaid and CHIP equal to the sum of the over payments and under payments in the sample, that is, the absolute value of such payments, expressed as a percentage of total payments made in the sample.
Medicaid means the joint Federal and State program, authorized and funded under Title XIX of the Act, that provides medical care to people with low incomes and limited resources.
Payment means any payment to a provider, insurer, or managed care organization for a Medicaid or CHIP beneficiary for which there is Medicaid or CHIP Federal financial participation. It may also mean a direct payment to a Medicaid or CHIP beneficiary in limited circumstances permitted by CMS regulation or policy.
Provider error includes, but is not limited to, medical review errors as described in § 431.960(c) of this subpart, as determined in accordance with documented State or Federal policies or both.
Recoveries mean those monies for which the State is responsible to pay back to CMS based on the identification of Federal improper payments.
State eligibility system means any system, within the State or with a state-delegated contractor, that is used by the state to determine Medicaid and/or CHIP eligibility and/or that maintains documentation related to Medicaid and/or CHIP eligibility determinations.
State error includes, but is not limited to, data processing errors and eligibility errors as described in § 431.960(b) and (d), as determined in accordance with documented State and Federal policies. State errors do not include the errors described in paragraph § 431.960(e)(2).
Statistical Contractor (SC) means the contractor responsible for collecting and sampling fee-for-service claims and managed care capitation payment data, as well as calculating Medicaid and CHIP state and national improper payment rates.
States means the 50 States and the District of Columbia.