Definitions

In this chapter, unless the context or subject matter otherwise requires: 1. "Abuse" means practices that: a. Are inconsistent with sound fiscal, business, or medical practices and result in an unnecessary cost to Medicaid and children's health insurance program; b. Elicit reimbursement for services that are not medically necessary; c. Are in violation of an agreement or certificate of coverage; or d. Fail to meet professionally recognized standards for health care. 2. "Administrative or fiscal agent" means an organization which processes and pays provider claims on behalf of the department. 3. "Affiliates" means persons having an overt or covert relationship each with the other such that any one of them directly or indirectly controls or has the power to control another. 4. "Business integrity agreement" means an agreement between the department and the provider that addresses the concerns of the department and recognizes essential elements of required compliance for the provider to preempt further sanction, exclusion from participation, or termination. 5. "Children's health insurance program" means a program to provide health assistance to low-income children funded through title XXI of the Social Security Act [42 U.S.C. 1397 aa et seq.]. 6. "Client share" means the amount of monthly net income remaining after all appropriate deductions, disregards, and Medicaid income levels have been allowed. This is also referred to as recipient liability. 7. "Credible allegation of fraud" means an allegation which has been verified by the department. 8. "Department" means the department of human services' medical services, aging services, and developmental disabilities divisions. 9. "Direct owner" means someone with an active ownership interest in the disclosing entity. 10. "Disclosing entity" means a Medicaid or children's health insurance program provider, excluding an individual practitioner or group of practitioners, or a fiscal agent, that is required to provide ownership and enrollment information. 11. "Exclusion from participation" means permanent removal from provider participation in the North Dakota medical assistance or children's health insurance program. 12. "Fraud" means deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to that person or another and includes an act that constitutes fraud under applicable federal or state law. 13. "Group of practitioners" means two or more health care practitioners who practice their profession at a common location. 14. "High-risk providers" means a provider or a provider type or specialty deemed by the department as high risk, based on federal regulations, policy, and guidance. 15. "Indirect ownership interest" means disclosing ownership interest in a disclosing entity, including an ownership interest in any entity that has an indirect ownership in the disclosing entity. 16. "Institutional provider" for purposes of assessing an application fee means those defined by centers for Medicare and Medicaid services or as deemed by the department based on federal regulations, policy, and guidance. 17. "Licensed practitioner" means an individual, other than a physician who is licensed or otherwise authorized by the state to provide health care services within the practitioner's scope of practice. 18. "Loss of contact" means postal mail sent to an enrolled provider at the last known address is returned to the department. 19. "Managed care organization" means an entity that has, or is seeking to qualify for, a comprehensive risk contract under 42 C.F.R. part 438, and that is: a. A federally qualified health management organization that meets the advance directives requirements of 42 C.F.R. 489.102; or b. Any public or private entity that meets the advance directives requirements and is determined by the secretary of the federal department of health and human services, or designee, to also make the services it provides to program enrollees as accessible as those services are to other Medicaid and children's health insurance program recipients within the area served by the entity and meets the solvency standards of 42 C.F.R. 438.116. 20. "Medicaid" means "medical assistance" and is a term precisely equivalent thereto. 21. "Ownership interest" means the possession of equity in the capital, the stock, or the profits of the disclosing entity. 22. "Person" means any natural person, company, firm, association, corporation, or other legal entity. 23. "Provider" means any individual or entity furnishing Medicaid or children's health insurance program services under a provider agreement with the department or managed care organization. 24. "Provider specialty" means the area that a provider specializes in. 25. "Provider type" means a general type of service or provider. 26. "Sanction" means an action taken by the department against a provider for noncompliance with a federal or state law, rule, or policy, or with the provisions of the Medicaid and children's health insurance program provider agreement. 27. "Suspend payments" means the withholding of payments due a provider until the matter in dispute between the provider and the department is resolved. 28. "Suspension from participation" means temporary suspension of provider participation in the Medicaid program for a specified period of time. 29. "Termination" means determining a provider to be indefinitely ineligible to be a Medicaid and children's health insurance program provider.