Definitions

Definitions A. Abuse is defined as beneficiary practices that result in unnecessary cost to the Medicaid program and/or provider practices that are inconsistent with sound fiscal, business, or medical practices that result in: 1. An unnecessary cost to the Mississippi Medicaid Program, 2. Reimbursement for services that are not medically necessary, or 3. Reimbursement for services that fail to meet professionally recognized standards for health care. B. Administrative Appeal is defined in Miss. Admin. Code Title 23, Part 300. C. Beneficiary error is defined as the beneficiary’s incomplete, incorrect or misleading information because the beneficiary misunderstood, was unable to comprehend the relationship of the facts about the situation to eligibility requirements or there was other inadvertent failure on the beneficiary’s part to supply the pertinent or complete facts affecting Medicaid or Children's Health Insurance Program (CHIP) eligibility. D. Corrective Action Plan (CAP) is defined as a documented plan that includes a well-defined identification of the problem, a specific time frame for the remedy to be implemented, specific actions taken to remedy the defined problem, plan on how to prevent the problem from recurring and the consequences if the problem is not resolved. At a minimum, the CAP must include: a) The specific obligations violated, b) The specific actions taken that address correction of the behavior that led to the violation(s), c) The duration of the CAP which must be greater than ninety (90) calendar days, and d) The means by which compliance with the CAP will be monitored and assessed. E. Credible allegation of fraud is defined as an allegation from any source that has indicia of reliability in which the Division of Medicaid has verified through facts and evidence including, but not limited to, alleged fraud from: 1. Fraud hotline complaints, 2. Claims data mining, and/or 3. Patterns identified through provider audits, civil false claims cases, and law enforcement investigations. F. Demand Letter is defined as a notification that a provider is required to refund improper payments. G. Fraud is defined as an 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, or an act that constitutes fraud as defined by federal or state law. H. Incorrect payment is defined as an error in reimbursement which results in an overpayment or underpayment which may be due to a billing error, systems error and/or human error. I. Overpayment is defined as any payment which results in a provider receiving any amount of reimbursement to which the provider is not legally entitled to receive. J. Peer Review (PR) is defined as a retrospective review of medical records by the Division of Medicaid’s Utilization Review/Quality Improvement Organization (UM/QIO) to assess if: a) Services and items were reasonable and medically necessary; b) The quality of services met professionally recognized standards of health care; c) The beneficiary received the appropriate health care in a safe, appropriate and cost- effective setting based on the beneficiary’s diagnosis and severity of the symptoms; d) Services were provided economically and only when and to the extent they were medically necessary; and e) The utilization billing and coding practices and/or overall utilization patterns of a provider for beneficiaries being reviewed are appropriate. K. Peer Review Consultant (PRC) is defined as the medical reviewer in a comparable specialty as the provider or a certified professional coder (CPC) when appropriate. L. Peer Review Panel (PRP) is defined as at least three (3) providers, at least one (1) of whom practices in the same class group as the subject provider; Selection of the PRP members shall ensure that their objectivity and judgment will not be affected by personal bias for or against the subject provider or by direct economic competition or cooperation with the subject provider. M. Reconsideration Review is defined as an impartial review of the case by a Peer Review Consultant not involved in the initial Peer Consultant Review determination, at the request of the Division of Medicaid, a provider, or as part of a UM/QIO follow-up. N. Waste is defined as the overutilization, underutilization, or misuse of resources.