The following words and terms, when used in this Chapter,
shall have the following meaning, unless the context clearly indicates
otherwise:
"1115(a) IMD waiver" means the 1115(a)
Institutions for Mental Disease (IMD) demonstration waiver for individuals with
Serious Mental Illness/Serious Emotional Disorder (SMI/SED) and Substance Use
Disorder (SUD), as amended and including all active special terms and
conditions (STCs) at a specific point in time, that authorizes Oklahoma Health
Care Authority (OHCA) to operate a program in which one (1) or more
requirements of Title XIX of the Social Security Act (Act) are waived based on
the waiver authority of Section 1115 of the Act.
"1915(c) waiver" means any waiver, authorized
by Section 1915(c) of the Act, that allows specific coverage of home and
community-based services to a limited group of Medicaid-Eligible individuals as
an alternative to institutional care.
"Abuse" means provider practices that are
inconsistent with sound fiscal, business, or medical practices, and result in
an unnecessary cost to the Medicaid program, or in reimbursement for services
that are not medically necessary or that fail to meet professionally recognized
standards for health care (as defined at
42 C.F.R. §
455.2). It also includes Eligible and Health
Plan Enrollee practices that result in unnecessary cost to the Medicaid
program.
"Accountable care organization" or
"ACO" means a network of physicians, hospitals, and other health
care providers that provide coordinated care to Medicaid members.
"Accrediting entity" means an entity recognized
by CMS under 45 C.F.R.
§
156.275. Current CMS-recognized
accrediting entities include Accreditation Association for Ambulatory Health
Care (AAAHC), National Committee for Quality Assurance (NCQA) and Utilization
Review Accreditation Commission (URAC). To the extent CMS recognizes additional
accrediting entities, OHCA will also permit the CE or DBM to achieve
accreditation from such entity to meet the requirements.
"Act" means the Social Security Act.
"Activities of daily living (ADL)" means
activities that reflect the Health Plan Enrollee's ability to perform selfcare
tasks essential for sustaining health and safety such as: bathing; eating;
dressing; grooming; transferring (includes getting in and out of the tub, bed
to chair, etc.); mobility; toileting and bowel/bladder control. The services
help with proper medical care, self-maintenance skills, personal hygiene,
adequate food, shelter, and protection.
"Administrative remedies" means an action taken
by the OHCA in response to the DBM's failure to comply with a requirement or
performance standard. Remedies, include but are not limit to, liquidated
damages, capitation payment suspension, auto-assignment suspension, contract
termination, and any other remedies outlined in the Contract.
"Adult" means an individual twenty-one (21)
years of age or older, unless otherwise specified by statute, regulation,
and/or policy adopted by the OHCA. For eligibility criteria policy for children
and adults, please refer to Oklahoma Administrative Code (OAC)
317:35-5-2.
"American Indian/Alaska Native" or
"AI/AN" means any individual as defined in
25 U.S.C. §§
1603(13),
1603(28) or
1679(a) or who
has been determined Eligible as an Indian under
42 C.F.R. §
136.12.
"Appeal" means a review by an CE or DBM of an
adverse benefit determination.
"Applicant" means an individual who seeks
SoonerCare coverage. "Authorized representative" means a competent adult who
has the Enrollee's signed, written authorization to act on the Enrollee's
behalf during the grievance, appeal, and state fair hearing process. The
written authority to act will specify any limits of the representation.
"Behavioral health services" means a wide range
of diagnostic, therapeutic and rehabilitative services used in the treatment of
mental illness, substance abuse, and co-occurring disorders.
"Business days" means Monday through Friday and
is exclusive of weekends and State of Oklahoma holidays.
"Calendar days" means all seven (7) days of the
week, including State of Oklahoma holidays.
"Capitated contract" means a contract between
OHCA and a contracted entity for the delivery of services to Medicaid members
in which OHCA pays a fixed, per-member per-month rate based on actuarial
calculations.
"Capitation payment" means a payment OHCA will
make periodically to the CE or DBM on behalf of each Health Plan Enrollee
enrolled under the Sooner Select program and based on the actuarially sound
capitation rate for the provision of services under the State Plan. OHCA shall
make the payment regardless of whether the Health Plan Enrollee receives
services during the period covered by the payment.
"Capitation rate" means the per Health Plan
Enrollee, per-month amount, including any adjustments, that is paid by OHCA to
the CE or DBM for each Health Plan Enrollee enrolled in the Sooner Select
program for the provision of services during the payment period.
"Care coordination/care management" means a
process that assesses, plans, implements, coordinates, monitors, and evaluates
the options and services required to meet the Health Plan Enrollee's needs
using advocacy, communication, and resource management to promote quality and
cost-effective interventions and outcomes. Based on the needs of the Health
Plan Enrollee, the care manager arranges services and supports across the
continuum of care, while ensuring that the care provided is
person-centered.
"Care manager" means the CE's staff primarily
responsible for delivering services to Health Plan Enrollees in accordance with
its OHCA-approved risk stratification level framework, and meets the
qualifications specified in the Contract.
"Care plan" means a comprehensive set of
actions and goals for the Health Plan Enrollee developed by the care manager
based on the unique needs of Health Plan Enrollee(s). The CE shall develop and
implement care plans for all Health Plan Enrollees with a special health care
need determined through the comprehensive assessment to need a course of
treatment or regular care monitoring and in accordance with Section 1.8.3:
"Care Plans" of the Contract.
"Case file" means an electronic record that
includes Enrollee information regarding the management of health care services
including but not limited to: Enrollee demographics; comprehensive assessment
(if applicable); care plan; reassessments; referrals and authorizations and
Enrollee case notes.
"CEO" means Chief Executive Officer.
"Certified community behavioral health clinic"
or ("CCBHC" or "CCBH") means entities designed to
provide a comprehensive range of mental health and substance use disorder
services as defined under the Excellence in Mental Health Act and certified by
the Oklahoma Department of Mental Health and Substance Abuse Services.
"C.F.R." means the Code of Federal
Regulations.
"Child" means an individual under twenty-one
(21) years of age, unless otherwise specified by statute, regulation, and/or
policy adopted by the OHCA. For eligibility criteria policy for children and
adults, please refer to OAC
317:35-5-2. "Child welfare
services" means the Oklahoma Human Services (OKDHS) division responsible for
administering Oklahoma's child welfare services.
"Children's Health Insurance Program" or
"CHIP" means a Medicaid program authorized under Title XXI of the
Social Security Act.
"Children's Specialty Plan" or "Children's
Specialty Program" means the single statewide health care plan that
covers all Medicaid services other than dental services and is designed to
provide care to children in foster care children, former foster care children
up to twenty-five (25) years of age, juvenile justice involved children, and
children receiving adoption assistance.
"Choice counseling" means the provision of
information and services designed to assist Eligibles in making enrollment
decisions as described in 42
C.F.R §
438.2. "Chronic condition" means
a condition that is expected to last one (1) year or more and requires ongoing
medical attention and/or limits activities of daily living (ADL).
"Civil monetary damage" means a damage imposed
by OHCA which the CE must pay for acting or failing to act in accordance with
42 C.F.R. §
438.700 et seq. Amounts may not exceed those
specified in 42 C.F.R.
§
438.704.
"Clean claim" means a properly completed billing
form with coding based on Current Procedural Terminology (CPT), fourth edition
or a more recent edition, the tenth revision of the International
Classification of Diseases (ICD) or a more recent revision, or Healthcare
Common Procedure Coding System (HCPCS), where applicable, to provide
information specifically required in the OHCA Provider Billing and Procedure
Manual.
"CMS" means Centers for Medicare & Medicaid
Services.
"Commercial plan" means an organization or
entity that undertakes to provide or arrange for the delivery of health care
services to Medicaid members on a prepaid basis and is subject to all
applicable state and federal laws and regulations.
"Continuity of care period" means the ninety
(90) day period immediately following an Enrollee's enrollment with the CE or
DBM whereby established Enrollee and provider relationships, current services
and existing prior authorizations and care plans shall remain in place.
"Contract" means a result of receiving an award
from OHCA and successfully meeting all Readiness Review requirements, the
agreement between the Contractor and OHCA where the Contractor will provide
Medicaid services to Sooner Select Enrollees, comprising of the Contract and
any Contract addenda, appendices, attachments, or amendments thereto, and be
paid by OHCA as described in the terms of the agreement.
"Contract year" means the period during which
the Contract is in effect. The initial Contract year shall be from date of
award through the end of the state fiscal year. Each subsequent Contract year
shall be based on state fiscal year.
"Contracted entity" or "CE" means
an organization or entity that enters into or will enter into a capitated
contract with the Oklahoma Health Care Authority (OHCA) for the delivery of
services that will assume financial risk, operational accountability, and
statewide or regional functionality in this act in managing comprehensive
health outcomes of Medicaid members. This includes an accountable care
organization, a provider-led entity, a commercial plan, a dental benefit
manager, or any other entity as determined by the OHCA.
"Contractor" means a contracted entity with
which OHCA has entered into a binding agreement for the purpose of procuring
services to Sooner Select program Enrollees as specified in the Contract. The
term "Contractor" includes all such Contractor's affiliates, agents,
subsidiaries, any person with an ownership or control interest, officers,
directors, manager, employees, independent contractors, and related parties
working for or on behalf of the Contractor and other parties.
"Copayment" means a fixed amount that an
Enrollee pays for a covered health care service when the Enrollee receives the
service.
"Corrective action plan" or "CAP"
means the detailed written plan that may be required by OHCA to correct or
resolve a deficiency, event, or breach.
"Cost sharing" means the state's requirement
that an Enrollee bear some of the cost of their care through mechanisms such as
copayments, deductibles, and other similar charges.
"Critical incident" means any actual or alleged
event or situation that creates a significant risk of substantial or serious
harm to the physical or mental health, safety, or well-being of a Sooner Select
program Health Plan Enrollee.
"Deemed newborn" means children born to
SoonerCare enrolled mothers and determined Eligible under
42 C.F.R. §
435.117.
"Dental benefits manager" or "DBM"
means an entity that meets the definition of a Prepaid Ambulatory Health Plan
(PAHP) as per 42 C.F.R.
§
438.2 and is under contract with the
OHCA to manage and deliver all services described in this Sooner Select Dental
Contract and who handles claims payment and prior authorizations and
coordinates dental care with participating providers and Enrollees. Also
referred to as a "Contractor".
"Dental related emergency services" means
services provided to a Sooner Select Dental Enrollee that are necessary for the
treatment of any condition requiring immediate attention for the relief of
pain, hemorrhage, acute infections, or traumatic injury to the teeth,
supporting structures (periodontal membrane, gingival, alveolar bone), jaws,
and tissue of the oral cavity.
"Disenrollment" means OHCA's removal of an
Enrollee from participation in a specific CE or DBM or from participation in
the Sooner Select program.
"Dual eligible individuals" means individuals
eligible for both Medicaid and Medicare.
"Eligible" means an individual who has been
deemed Eligible for the Sooner Select program but who is not yet enrolled in a
CE or DBM.
"Emergency medical condition" means a medical
condition, including injury, manifesting itself by acute symptoms of sufficient
severity, including severe pain, that a prudent layperson who possesses an
average knowledge of health and medicine could reasonably expect the absence of
immediate medical attention to result in placing the individual's health, or
the health of an unborn child, in serious jeopardy, serious impairment to
bodily functions or serious dysfunction of any bodily organs or parts.
"Emergency services" means medical services
provided for a medical condition, including injury, manifesting itself by acute
symptoms of sufficient severity, including severe pain, that a prudent
layperson who possesses an average knowledge of health and medicine could
reasonably expect the absence of immediate medical attention to result in
placing the individual's health, or the health of an unborn child, in serious
jeopardy, serious impairment to bodily functions or serious dysfunction of any
bodily organs or parts.
"Encounter data" means information relating to
the receipt of any item(s) or service(s) by an Enrollee under the Contract that
is subject to the requirements of
42 C.F.R. §§
438.242 and
438.818.
"Enrollee" means an individual who has been
deemed Eligible for Medicaid in the State of Oklahoma, who has been deemed
Eligible for enrollment in the Sooner Select program, and who is currently
enrolled in the Sooner Select program.
"Enrollee handbook" means a guidebook that
explains the Sooner Select program that the Contactor shall distribute to every
Enrollee. It shall be designed to help the Enrollee understand the CE or DBM,
the Sooner Select program and the rights and responsibilities that come with
membership in the program.
"Enrollment" means the OHCA process by which an
Eligible becomes an Enrollee with an CE or DBM.
"Essential community provider" means a provider
defined by 45 C.F.R. §
156.235. "Excluded populations" means
populations that are excluded from participation in the Sooner Select program
as specified in the Contract.
"Expansion adult" means an individual nineteen
(19) or older and under age sixty-five (65), with income at or below one
hundred thirty-eight percent (138%) of the federal poverty level (FPL)
determined Eligible in accordance with
42 C.F.R. §
435.119), and who are not categorically
related to the aged, blind, and disabled.
"Federally Qualified Health Center (FQHC)" or
"Health Centers" or "Centers" means an organization
that qualifies for reimbursement under Section 330 of the Public Health Service
Act. FQHCs qualify to receive enhanced reimbursements from Medicare and
Medicaid, must serve an underserved population or area, offer a sliding fee
scale, provide comprehensive services, have an ongoing quality assurance
program, and have a governing board of directors.
"Former foster care children" or
"FFC" means individuals under age twenty-six (26) determined
Eligible in accordance with 42 C.F.R. §
435.150 who were
in foster care under the responsibility of the State or an Indian Tribe within
Oklahoma and enrolled in SoonerCare on the date of attaining age eighteen (18)
or aging out of foster care.
"Foster care" means planned, goal-directed
service that provides twenty-four (24) hour a day substitute temporary care and
supportive services in a home environment for children birth to eighteen (18)
years of age in OKDHS custody.
"Foster children (FC)" means children in foster
care under the responsibility of the State, including children and youth who
are in State custody due to abuse or neglect.
"FPL" means federal poverty level.
"Fraud" means 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. It
includes any act that constitutes fraud under applicable federal or state
law.
"Grievance" means an Enrollee's expression of
dissatisfaction about any matter other than an adverse benefit determination.
Grievances may include, but are not limited to, the quality of care or services
provided, aspects of interpersonal relationships such as rudeness of a provider
or employee or failure to respect the Enrollee's rights regardless of whether
remedial action is requested. A grievance includes an Enrollee's right to
dispute an extension of time proposed by the CE or DBM to make an authorization
decision.
"Grievance and appeal system" means the
processes the CE or DBM must implement in accordance with 42 C.F.R. Part 438,
Subpart F, to handle Enrollee grievances and appeals, as well as the processes
to collect and track information about them.
"Health care services" means all services
outlined in the Oklahoma Medicaid State Plan, the Alternative Benefit Plan, and
the 1115(a) IMD Waiver that are provided, according to contract, by the CE or
DBM in any setting. Health care services may include but are not limited to
medical care, behavioral health care, dental care, and pharmacy services.
"Health plan" means the same in these rules as at 36 O.S. § 4405.1.
"Hospitalization" means care in a hospital that requires admission as an
inpatient and usually requires an overnight stay.
"Implementation" means the process by which
OHCA and the CE or DBM performs actions and responsibilities to actively
implement a managed care program or contract for the first time. Implementation
also means, depending on its use, the moment in time that such actions and
responsibilities are fully completed.
"Indian health care provider" or
"IHCP" means a health care program operated by the Indian Health
Service (IHS) or by an Indian Tribe, Tribal Organization, or Urban Indian
Organization (otherwise known as an I/T/U) as those terms are defined in
Section 4 of the Indian Health Care Improvement Act (25 U.S.C. §
1603). "Initial enrollment" means an
Eligible's enrollment in an CE or DBM during the initial enrollment
period.
"Intermediate sanction(s)" means the sanctions
described in 42 C.F.R §
438.702, which the OHCA may impose for the
contracted entities non-compliance for any of the conditions in
42 C.F.R. §
438.700.
"Juvenile justice involved" means any person in
custody or under the supervision of the Oklahoma Office of Juvenile Affairs
(OJA) for whom OJA is required to provide services by law or court
order.
"Manual" or "guide" means any
document, outside of the Medicaid State Plan, any Medicaid waiver, and the
rules, that is created by or for OHCA for use in interpreting or implementing
contractual terms.
"Manual" is synonymous with guide, guidebook,
companion guide, manual, reference book, dictionary, handbook, model,
instructions, primer, workbook, or any other words denoting a document that is
handled as a matter of convenience.
"Medical necessity" or "medically
necessary" means a standard for evaluating the appropriateness of
services as established under OAC
317:30-3-1.
"National provider identifier (NPI)" means a
unique identification number for covered health care providers. Covered health
care providers and all CEs, DBMs, and health care clearinghouses must use an
NPI in the administrative and financial transactions adopted under the Health
Insurance Portability and Accountability Act (HIPAA). The NPI is a
ten-position, intelligence-free numeric identifier (ten-digit number). This
means that the numbers do not carry other information about healthcare
providers, such as the state in which they live or their medical specialty. The
NPI must be used in lieu of legacy provider identifiers in the HIPAA standards
transactions.
"Non-compliance remedy" means an action taken by
OHCA in response to the Contractor's failure to comply with a contract
requirement or performance standard.
"Non-participating provider" means a physician
or other provider who has not contracted with or is not employed by the CE or
DBM to deliver services under the Sooner Select program.
"Non-urgent sick visit" means medical care
given for an acute onset of symptoms which is not emergent or urgent, but which
requires face-to-face medical attention within seventy-two (72) hours of
Enrollee notification of a nonurgent condition, as clinically indicated.
Examples of non-urgent sick visits include cold symptoms, sore throat, and
nasal congestion.
"OAC" means Oklahoma Administrative
Code.
"OHCA" means the Oklahoma Health Care
Authority.
"OJA" means the Office of Juvenile
Affairs.
"OKDHS" means the Oklahoma Department of Human
Services which is also referenced in rules as Department of Human Services
(DHS) and Office of Human Services (OHS).
"Open enrollment period" means the annual
period of time, as defined by contract, when Enrollees and Eligibles can enroll
in and select an CE or DBM for the Sooner Select program.
"O.S." means Oklahoma Statutes.
"Parent and caretaker relative" means an
individual determined Eligible under
42 C.F.R. §
435.110.
"Participating provider" means a physician or
other provider who has a contract with or is employed by a CE or DBM to provide
health care services to Enrollees under the Sooner Select Medical or Dental
program.
"Post-stabilization care services" means covered
services related to an emergency medical condition that are provided after a
Health Plan Enrollee is stabilized to maintain the stabilized condition or
under the circumstances described in
42 C.F.R. §
438.114(e), to improve or
resolve the Health Plan Enrollee's condition.
"Pregnant women" means women determined Eligible
for SoonerCare under 42
C.F.R. §
435.116.
"Prepaid Ambulatory Health Plan" or
"PAHP" means a DBM and/or an entity as per
42 C.F.R. §
438.2 that:
(A) Provides services to Enrollees under
contract with the state, and on the basis of capitation payments, or other
payment arrangements that do not use State Plan payment rates;
(B) Does not provide or arrange for, and is
not otherwise responsible for the provision of any inpatient hospital or
institutional services for its Enrollees; and
(C) Does not have a comprehensive risk
contract.
"Prepaid dental plan" means a contractual
arrangement in accordance with 36 O.S. § 6142, whereby any prepaid dental
plan organization undertakes to provide payment of dental services directly, or
to arrange for prepaid dental services, or to pay or make reimbursement for any
dental services not provided for by other insurance.
"Prepaid dental plan organization" means any
person who undertakes to conduct one (1) or more prepaid dental plans providing
only dental services in accordance with 36 O.S. § 6142.
"Presumptive eligibility" means a period of
temporary SoonerCare eligibility for individuals who are categorically related
to certain eligibility groups listed in OAC
317:35-6-38(a)(1)(A)(i) through
(vi) and are also determined by a qualified
entity, on the basis of applicant self-attested income information, to meet the
eligibility requirements for a Modified Adjusted Gross Income (MAGI)
eligibility group.
"Primary care" means the provision of
integrated, equitable, and accessible health care services by clinicians who
are accountable for addressing a large majority of personal health care needs,
developing a sustained partnership with patients, and practicing in the context
of family and community.
"Primary care dentist" or "PCD"
means a dental care professional providing comprehensive dental care for a
Dental Health Plan Enrollee. "Primary care provider" or "PCP" means the
following:
(A) Family medicine
physicians in an outpatient setting when practicing general primary
care;
(B) General pediatric
physicians and adolescent medicine physicians in an outpatient setting when
practicing general primary care;
(C)
Geriatric medicine physicians in an outpatient setting when practicing general
primary care;
(D) Internal medicine
physicians in an outpatient setting when practicing general primary care
(excludes internists who subspecialize in areas such as cardiology, oncology,
and other common internal medicine subspecialties beyond the scope of general
primary care);
(E) Obstetrics and
gynecology physicians in an outpatient setting when practicing general primary
care;
(F) Providers such as nurse
practitioners and physicians' assistants in an outpatient setting when
practicing general primary care; or
(G) Behavioral health providers, including
psychiatrists, providing mental health and substance use disorder services when
integrated into a primary care setting.
"Prior authorization" or "PA"
means a requirement that an Enrollee, through the Enrollee's provider, obtain
the CEs or DBM's approval before a requested medical service is provided or
before services by a non-participating provider are received. Prior
authorization is not a guarantee of claims payment; however, failure to obtain
prior authorization may result in denial of the claim or reduction in payment
of the claim.
"Protected health information" or
"PHI" means information considered to be individually identifiable
health information, per 42 C.F.R.§ 160.103.
"Provider" means a health care services
provider licensed or certified in this State.
"Provider agreement" means an agreement between
the CE or DBM and a participating provider that describes the conditions under
which the participating provider agrees to furnish covered health care services
to Enrollees.
"Provider-led entity" means an organization or
entity that meets the criteria of at least one (1) of the following:
(A) A majority of the entity's ownership is
held by Medicaid providers in this state or is held by an entity that directly
or indirectly owns or is under common ownership with Medicaid providers in the
state; or
(B) A majority of the
entity's governing body is composed of individuals who:
(i) Have experience serving Medicaid members
and:
(I) Are licensed in the state as
physicians, physician assistants, nurse practitioners, certified
nurse-midwives, or certified registered nurse anesthetists;
(II) At least one (1) board member is a
licensed behavioral health provider; or
(III) Are employed by a hospital or other
medical facility licensed by the state and operating in the state or an
inpatient or outpatient mental health or substance abuse treatment facility or
program licensed or certified by the state and operating in the
state.
(ii) Represent the
providers or facilities including, but not limited to, individuals who are
employed by a statewide provider association; or
(iii) Are nonclinical administrators of
clinical practices serving Medicaid members.
"Quality Assessment and Performance
Improvement" or "QAPI" means a process designed to address and
continuously improve CE and DBM quality metrics.
"Risk contract" means a contract between OHCA
and a CE, prepaid inpatient health plan (PIHP), or prepaid ambulatory health
plan (PAHP), as those terms are defined at
42 C.F.R. §
438.2, under which the Contractor assumes
risk for the cost of the services covered under the contract and incurs loss if
the cost of furnishing the services exceeds the payments under the
Contract.
"Rural area" means a county with a population
of less than fifty thousand (50,000) people.
"Rural Health Clinic" or "RHC"
means clinics meeting the conditions to qualify for RHC reimbursement as
stipulated in Section 330 of the Public Health Services Act.
"SoonerCare" means the Oklahoma Medicaid
program.
"Sooner Select" means the CEs and DBMs with
whom the OHCA contracts with to provide SoonerCare covered medical, dental,
pharmacy, and behavioral health benefits.
"Soon-To-Be-Sooner" means Oklahoma's separate
CHIP providing coverage to unborn children of families earning up to and
including one hundred eighty-five percent (185%) of the FPL.
"State Plan" means an agreement between OHCA and
CMS describing how Oklahoma administers its Medicaid and CHIP programs.
"Steady state operations" or "steady
state" means the time period beginning ninety (90) days after initial
program implementation.
"Third party liability" or "TPL"
means all or part of the expenditures for an Enrollee's medical or dental
assistance furnished under the Oklahoma Medicaid State Plan that may be the
liability of a third-party individual, entity, or program.
"Urban area" means a county with a population
of fifty thousand (50,000) people or more.
"U.S.C." means United States Code. "Value-added
benefit" means any benefit or service offered by a CE or DBM when that benefit,
or service is not a covered benefit per the State Plan. These benefits are
subject to change annually as determined by the CE or DBM and OHCA.
"Value-based payment arrangement" means a
payment arrangement between a CE or DBM and its participating providers when
payment is intentionally aligned with quality measures OHCA applies to the CE
or DBM.
"Waste" means the overutilization of services,
or other practices that, directly or indirectly, result in unnecessary costs to
the Medicaid program; generally, not considered to be caused by criminally
negligent actions but rather the misuse of resources.
