N.M. Admin. Code § 8.308.22.7 - DEFINITIONS

A. "Abuse" is provider practices that are inconsistent with sound fiscal, business, or clinical practices, and result in unnecessary costs to the medicaid program, or in reimbursement of services that fail to meet professionally recognized standards for health care.

B. "Credible allegation of fraud" means an allegation, which has been verified by the state, from any source, including but not limited to the following:

(1) fraud hotline complaint;

(2) claims data mining;

(3) patterns identified through provider audits;

(4) civil false claims cases; or

(5) law enforcement investigations; see 42 CFR 455.2.

C. "Fraud" means an intentional deception or misrepresentation by a person or an entity, with knowledge that the deception could result in some unauthorized benefit to him or herself or some other person. It includes any act that constitutes fraud under applicable federal or state statutes, regulations and rules.

D. "MFEAD" is the medicaid fraud and elder abuse division of the New Mexico attorney general's office

E. "Overpayment" means any funds that a person or entity receives or retains in excess of the medicaid allowable amount; however, for purposes of this rule, an overpayment does not include funds that have been subject to a payment suspension or that have been identified as third-party liability.

F. "Provider" means a network provider and non-network provider.

G. "Recovery" means money received by HSD or MFEAD for fraud or credible allegations of fraud from a provider.

H. "Refund" means money returned by a provider for overpayment(s).

I. "Waste" is the overutilization of services or other practices that result in unnecessary costs.

Notes

N.M. Admin. Code § 8.308.22.7

8.308.22.7 NMAC - N, 1-1-14