471 Neb. Admin. Code, ch. 2, § 002 - DEFINITIONS

The following definitions apply:

002.01 ABUSE. Practices or actions that are inconsistent with sound fiscal, business, or medical practices and result in an unnecessary cost to Medicaid or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. Abuse may include underutilization or overutilization.

002.02 AFFILIATES. Persons having an overt or covert relationship such that any one of them directly or indirectly controls or has the power to control another.

002.03 BILLING. Presenting, or causing to be presented, a claim for payment to the Department, its agents, or assignees.

002.04 BILLING AGENT. An entity that submits or facilitates the submission of claims for payment to the Department.

002.05 CLAIM. A request for payment for services rendered or supplied by a provider to a client.

002.06 CLEARINGHOUSE. An entity that processes or facilitates the processing of information received from another entity in the following formats:

(A) In a nonstandard format or containing nonstandard data content into a standard transaction; or

(B) In a standard transaction into nonstandard format or data content.

002.07 CLOSED-END PROVIDER ENROLLMENT. An enrollment that is for a specific period of time.

002.08 EXCLUDED PERSON OR ENTITY. Any individual or entity that is no longer eligible to participate as a provider, owner, managing employee, affiliate, or other individual or entity associated with an enrolled provider in Medicaid due to a sanction.

002.09 EXCLUSION. Prohibition from participating in Medicaid or affiliating with an enrolled provider.

002.10 FRAUD. An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself, herself, or some other person. It includes any act that constitutes fraud under applicable federal or state law.

Fraud includes, but is not limited to, the willful false statement or representation, or impersonation or other device, made by a client, applicant, provider, Department employee, or any other person, for the purpose of obtaining or attempting to obtain, or aiding or abetting any person to obtain:

(A) An assistance certificate of award to which the individual is not entitled;

(B) Any commodity, food stuff, food coupon, or payment to which the individual is not entitled or a larger amount of payment than that to which the individual is entitled;

(C) Any payment made on behalf of a client of medical assistance or social services;

(D) Any other benefit administered by the State of Nebraska, its agents or assignees; or

(E) Assistance in violation of any statutory provision relating to programs administered by the Department.

002.11 INITIAL ENROLLMENT. A provider's first time enrolling with Medicaid.

002.12 MANAGING EMPLOYEE. With respect to an entity, an individual, including a general manager, business manager, administrator, or director, who exercises operational or managerial control over the entity, or who directly or indirectly conducts the day-to-day operations of the entity.

002.13 MEDICAID EXCLUDED PROVDERS LIST. List of providers, persons, and entities that have been terminated or excluded from participation with Medicaid.

002.14 OPEN-ENDED PROVIDER ENROLLMENT. An enrollment that has no termination date and continues in force as long as the provider satisfies the applicable eligibility criteria.

002.15 OTHER INDIVIDUALS OR ENTITIES ASSOCIATED WITH THE ENROLLED PROVIDER. Ancillary healthcare professionals or staff who do not see Medicaid patients but are associated with a provider.

002.16 OVERUTILIZATION. Overutilization includes:

(A) A documented pattern of ordering, performing, or billing tests, examinations, medical visits, surgeries, drugs, or merchandise for which there is no demonstrable need; or

(B) Inducing, furnishing, or otherwise causing a client to receive services or merchandise not otherwise required by the client, ordered by the attending physician, or deemed appropriate by a utilization review committee.

002.17 OVERPAYMENT. Any erroneous payment to a provider, whether made due to the result of fraud, waste, abuse, inadvertence, or Department error.

002.18 PARTICIPATION. Participation in Medicaid includes providing, referring, furnishing, ordering, or prescribing services to a Medicaid client or causing services to be provided, referred, furnished, ordered, or prescribed for a Medicaid client.

002.19 PAYMENT. Reimbursement or compensation by the Department, its agents, assignees, or managed care plans.

002.20 PERSON. Any individual, company, firm, association, corporation, or other legal entity.

002.21 PERSON WITH AN OWNERSHIP OR CONTROL INTEREST. A person who:

(A) Has directly or indirectly an ownership interest of five percent or more in the entity;

(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 or any of the property or assets thereof, which whole or part interest is equal to or exceeds five percent of the total property and assets of the entity;

(C) Is an officer or director of the entity, if the entity is organized as a corporation; or

(D) Is a partner in the entity, if the entity is organized as a partnership.

002.22 PATIENT WAIVER. An agreement by which the client agrees to release his or her medical records to state or federal authorities accomplished by the client signing the, "Application for Assistance."

002.23 REACTIVATION. Enrollment of a provider whose previous service provider enrollment was terminated or excluded by the Department, and removal from the Medicaid excluded providers list.

002.24 RE-ENROLLMENT. Enrollment of a provider whose previous service provider enrollment expired or was voluntarily closed by the provider.

002.25 REVALIDATION. Process by which the Department confirms a provider's enrollment-related information is valid, updated, and accurate.

002.26 TERMINATION FROM PARTICIPATION. An exclusion from participation in Medicaid.

002.27 TRADING PARTNER AGREEMENT. An agreement related to the electronic exchange of information between the Department and a trading partner.

002.28 TRADING PARTNER. A health care plan, provider, or clearinghouse that transmits any health information in electronic form.

002.29 UNDERUTILIZATION. Not furnishing required services, or a lack of treatment or referrals when there is a demonstrable need.

002.30 USUAL AND CUSTOMARY CHARGE. The provider's charges to the general public for equivalent goods or services.

002.31 WITHHOLDING OF PAYMENTS. An adjustment of the amounts paid to the provider on pending and subsequently submitted claims to offset overpayments previously made to the provider.

Notes

471 Neb. Admin. Code, ch. 2, § 002

Adopted effective 2/10/2020 Amended effective 9/21/2020