23 Miss. Code. R. 305-1.1 - Definitions
A. Abuse is defined
as beneficiary practices that result in unnecessary cost to the Medicaid
program and/or provider practices that are inconsistent with sound fiscal,
business, or medical practices that result in:
1. An unnecessary cost to the Mississippi
Medicaid Program,
2. Reimbursement
for services that are not medically necessary, or
3. Reimbursement for services that fail to
meet professionally recognized standards for health care.
B. Administrative Hearing is defined as a
trial-like proceeding before the Division of Medicaid at which evidence and
testimony may be offered.
C.
Beneficiary error is defined as the beneficiary's incomplete, incorrect or
misleading information because the beneficiary misunderstood, was unable to
comprehend the relationship of the facts about the situation to eligibility
requirements or there was other inadvertent failure on the beneficiary's part
to supply the pertinent or complete facts affecting Medicaid or Children's
Health Insurance Program (CHIP) eligibility.
D. Corrective Action Plan (CAP) is defined as
a documented plan that includes a well-defined identification of the problem, a
specific time frame for the remedy to be implemented, specific actions taken to
remedy the defined problem, plan on how to prevent the problem from recurring
and the consequences if the problem is not resolved. At a minimum, the CAP must
include:
a) The specific obligations
violated,
b) The specific actions
taken that address correction of the behavior that led to the
violation(s),
c) The duration of
the CAP which must be greater than ninety (90) calendar days, and
d) The means by which compliance with the CAP
will be monitored and assessed.
E. Credible allegation of fraud is defined as
an allegation from any source that has indicia of reliability in which the
Division of Medicaid has verified through facts and evidence including, but not
limited to, alleged fraud from:
1. Fraud
hotline complaints,
2. Claims data
mining, and/or
3. Patterns
identified through provider audits, civil false claims cases, and law
enforcement investigations.
F. Demand Letter is defined as a notification
that a provider is required to refund improper payments.
G. Fraud is defined as an intentional
deception or misrepresentation made by a person with the knowledge that the
deception could result in some unauthorized benefit to himself or some other
person, or an act that constitutes fraud as defined by federal or state
law.
H. Incorrect payment is
defined as an error in reimbursement which results in an overpayment or
underpayment which may be due to a billing error, systems error and/or human
error.
I. Overpayment is defined as
an incorrect payment that results in the provider receiving a higher
reimbursement than is appropriate for the service provided.
J. Peer Review (PR) is defined as a
retrospective review of medical records by the Division of Medicaid's
Utilization Review/Quality Improvement Organization (UM/QIO) to assess if:
a) Services and items were reasonable and
medically necessary;
b) The quality
of services met professionally recognized standards of health care;
c) The beneficiary received the appropriate
health care in a safe, appropriate and costeffective setting based on the
beneficiary's diagnosis and severity of the symptoms;
d) Services were provided economically and
only when and to the extent they were medically necessary; and
e) The utilization billing and coding
practices and/or overall utilization patterns of a provider for beneficiaries
being reviewed are appropriate.
K. Peer Review Consultant (PRC) is defined as
the medical reviewer in a comparable specialty as the provider or a certified
professional coder (CPC) when appropriate.
L. Peer Review Panel (PRP) is defined as at
least three (3) providers, at least one (1) of whom practices in the same class
group as the subject provider; Selection of the PRP members shall ensure that
their objectivity and judgment will not be affected by personal bias for or
against the subject provider or by direct economic competition or cooperation
with the subject provider.
M.
Reconsideration Review is defined as an impartial review of the case by a Peer
Review Consultant not involved in the initial Peer Consultant Review
determination, at the request of the Division of Medicaid, a provider, or as
part of a UM/QIO follow-up.
N.
Waste is defined as the overutilization, underutilization, or misuse of
resources.
Notes
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No prior version found.