1 Tex. Admin. Code § 352.3 - Definitions
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
(1) Applicant--An
individual or an entity that submits an enrollment application to enroll or
re-enroll as a provider or to enroll a new practice location in Medicaid or
CHIP as described in paragraph (7) of this section.
(2) CHIP--The Texas State Children's Health
Insurance Program established under Title XXI of the federal Social Security
Act (42 U.S.C. §§
1397aa, et seq.) and Chapter 62 of the Health
and Safety Code.
(3) Change of
ownership--A change of ownership related to a partnership, sole proprietorship,
corporation, or leasing arrangement as defined in
42 CFR §
489.18.
(4) Designee--An entity to which HHSC has
delegated certain functions for provider enrollment purposes. A designee may
include:
(A) an HHSC contractor;
(B) a health and human services agency;
or
(C) a managed care organization
(MCO) that contracts with HHSC under Medicaid or CHIP.
(5) Disenroll--To end a provider's
participation in Medicaid or CHIP before the end of the provider's current
enrollment period.
(6)
Enrollment--The process for applying to become a provider, including
contracting and procedures for determining whether to grant approval to enter
into a provider agreement.
(7)
Enrollment application--Documentation required by HHSC that an applicant
submits to HHSC to enroll or re-enroll as a provider or to add a new practice
location. An enrollment application includes supplemental forms used to add
practice locations for Medicare-enrolled or limited-risk providers, as
determined by HHSC.
(8) Enrollment
type--A type of enrollment category that identifies how the applicant seeks to
enroll, such as individual, group, performing provider, or facility.
(9) Entity--A provider group, a facility, an
organization, or a business registered with the Texas Secretary of
State.
(10) Health care
practitioner--A physician or non-physician licensed or certified health care
provider who is recognized by federal law or by HHSC as a provider who can bill
for medical services or benefits, submits orders or referrals for services to
treat, certifies medical need for services, or supervises other individuals
providing services and benefits to Medicaid or CHIP recipients.
(11) Health and human services agency--A
state agency identified in Texas Government Code §
521.0001(5).
(12) HHSC--The Texas Health and Human
Services Commission or its designee.
(13) Medicaid--The medical assistance
program, a state and federal cooperative program authorized under Title XIX of
the Social Security Act that pays for certain medical and health care costs for
people who qualify.
(14) National
Provider Identifier--A unique ten-digit identification number assigned by the
Centers for Medicare & Medicaid Services.
(15) Overpayment--A payment made to a
provider in excess of the amount that is allowable for the service provided,
plus any accrued interest.
(16)
Person with an ownership or control interest--Has the meaning assigned by
§371.1003 of this title (relating to Definitions).
(17) Provider--An applicant that successfully
completes the enrollment process outlined in this chapter and in Chapter 371 of
this title (relating to Medicaid and Other Health and Human Services Fraud and
Abuse Program Integrity).
(18)
Provider agreement--An agreement between HHSC and a provider wherein the
provider agrees to certain contract provisions as a condition of
participation.
(19) Re-enrolling
provider--A provider that submits an enrollment application before the end of
the provider's current enrollment period.
(20) Recipient--A person receiving benefits
under Medicaid or CHIP.
(21) Surety
bond--One or more bonds issued by one or more surety companies under
31 U.S.C. §§
9304-
9308 and 31 CFR parts 223, 224,
and 225.
(22) Terminate--To take an
adverse action against a provider whose participation in Medicaid or CHIP has
ended at federal or state agency direction due to violation of state rules or
federal regulations.
(23)
Third-party billing vendor--A vendor registered with HHSC or its designee that
submits claims for reimbursement on behalf of a provider.
Notes
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No prior version found.