Utah Admin. Code R414-22-2 - Definitions
The definitions in Rule R414-1 apply to this rule. In addition:
(1) "Abuse" means provider
practices that are inconsistent with sound fiscal, business, or medical
practices, and result in reimbursement for services that are either not
medically necessary or fail to meet professionally recognized standards for
health care.
(2) "Conviction" or
"convicted" means a criminal conviction entered by a federal or state court for
fraud involving Medicare or Medicaid regardless of whether an appeal from
judgment is pending.
(3) "Fiscal
agent" means an organization that processes and pays provider claims on behalf
of the department.
(4) "Fraud"
means intentional deception or misrepresentation made by a person that results
in some unauthorized Medicaid benefit to the person or someone else. It
includes any act that constitutes fraud under applicable state law.
(5) "Member" means an individual who is
determined eligible for Medicaid.
(6) "Offense" means any of the grounds for
sanctioning set forth in Section
R414-22-4.
(7) "Person" means any natural person,
company, firm, association, corporation, or other legal entity.
(8) "Practitioner" means a physician or other
individual licensed under state law to practice their profession.
(9) "Provider" means an individual or other
entity approved by the department to provide services to Medicaid members that
has signed a provider agreement with the department.
(10) "Provider Sanction Committee" means the
committee within the department that determines whether a Medicaid provider
with a conviction or other sanction identified in Subsection
R414-22-3 (3), (4), or
(5) may enroll or remain in the Medicaid
program. This committee consists of a designee of the Executive Director of the
department, a designee of the Office of Inspector General of Medicaid Services
(OIG), and the office director over provider enrollment.
(11) "Suspension" means a status in which the
Division of Professional Licensing (DOPL) or an equivalent entity in another
state classifies a provider, which results in the department not adjudicating
or reimbursing claims submitted by that provider.
(12) "Termination from participation" means
termination of the existing provider agreement.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.