Texas Register, Volume 37, Number 40, Pages 7815-8094, October 5, 2012 Page: 8,000
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(4) At the time of the request--Immediately upon request
and without delay.
(5) Audit--A financial audit, attestation engagement, per-
formance audit, compliance audit, economy and efficiency audit, effec-
tiveness audit, special audit, agreed-upon procedure, nonaudit service,
or review conducted by or on behalf of the state or federal government.
An audit may or may not include site visits to the provider's place of
business.
(6) Auditor--The qualified person, persons, or entity per-
forming the audit on behalf of the state or federal government.
(7) Business day--A day that is not a Saturday, Sunday, or
state legal holiday. In computing a period of business days, the first day
is excluded and the last day is included. If the last day of any period
is a Saturday, Sunday, or state legal holiday, the period is extended to
include the next day that is not a Saturday, Sunday, or legal holiday.
(8) CFR--The Code of Federal Regulations.
(9) CHIP--The Texas Children's Health Insurance Program
or its successor.
(10) Claim--
(A) A written or electronic application, request, or de-
mand for payment by the Medicaid or other HHS program for health
care services or items; or
(B) A submitted request, demand, or representation that
states the income earned or expense incurred by a provider in providing
a product or a service and that is used to determine a rate of payment
under the Medicaid or other HHS program.
(11) Claims administrator--The entity designated by an op-
erating agency to process and pay Medicaid or HHS program provider
claims.
(12) Closed-end contract--A contract or provider agree-
ment for a specific period of time. It may include any specific
requirements or provisions deemed necessary by OIG to ensure the
protection of the program. It must be renewed for the provider to
continue to participate in the Medicaid or other HHS program.
(13) CMS--The Centers for Medicare & Medicaid Services
or its successor. CMS is the federal agency responsible for adminis-
tering Medicare and overseeing state administration of Medicaid and
CHIP.
(14) Commission--The Texas Health and Human Services
Commission or its successor.
(15) Controlled substance--"Controlled substance" as de-
fined by the Texas Controlled Substances Act (Texas Health and Safety
Code, Chapter 481) or its successor and the Federal Controlled Sub-
stances Act (21 U.S.C. 802(a)(6) et seq.) or its successor.
(16) Conviction or convicted--Means that:
(A) a judgment of conviction has been entered against
an individual or entity by a federal, state, or local court, regardless of
whether:
(i) there is a post-trial motion or an appeal pending;
or
(ii) the judgment of conviction or other record relat-
ing to the criminal conduct has been expunged or otherwise removed;
(B) a federal, state, or local court has made a finding of
guilt against an individual or entity;(C) a federal, state, or local court has accepted a plea of
guilty or nolo contendere by an individual or entity; or
(D) an individual or entity has entered into participation
in a first offender, deferred adjudication or other program or arrange-
ment where judgment of conviction has been withheld.
(17) Costs related to an administrative appeal--Such costs
include:
(A) the hourly State Office of Administrative Hearings
(SOAH) or other administrative hearing process costs;
(B) court reporter costs and the costs of transcripts and
copies of transcripts developed in preparation for, during, or after the
hearing;
(C) OIG's or other agency's costs associated with
discovery, including the costs of depositions, subpoenas, service of
process, and witness expenses;
(D) witness expenses incurred at any time related to the
administrative appeal, including during discovery or the case in chief;
(E) travel and per diem for witnesses and OIG or other
staff and witness fee;
(F) cost of preparation time, including salaries, travel
and per diem, any additional costs associated with the appeal hearing
or the preparation for the appeal hearing;
(G) all other reasonable costs, including attorney's fees,
associated with any further litigation of the case and the preparation for
that litigation; and
(H) costs incurred during the investigation or audit of a
case.
(18) Credible allegation of fraud--An allegation of fraud
that has been verified by the state from any source, including fraud
hotline complaints, claims data mining and patterns identified through
provider audits, civil false claims cases, and law enforcement investi-
gations.
(19) Delivery of a health care item or service--Includes the
provision of any item or service to an individual to meet his or her
physical, mental or emotional needs or well-being, whether or not re-
imbursed under Medicare, Medicaid, or any federal health care pro-
gram.
(20) Exclusion--Prohibition from participation in Medic-
aid.
(21) Executive Commissioner--The Executive Commis-
sioner of the Texas Health and Human Services Commission or its
successor.
(22) False statement or misrepresentation--Any statement
or representation that is inaccurate, incomplete, or not true.
(23) Federal financial participation (FFP)--The federal
government's share of a state's expenditures under the Medicaid and
other HHS programs and other benefit programs.
(24) Federal health care program--Any plan or program
that provides health benefits, whether directly, through insurance, or
otherwise, which is funded directly, in whole or in part, by the United
States Government (other than the federal employee health insurance
program under Chapter 89 of Title 5, United States Code).
(25) Field work--With respect to an investigation or audit,
field work may include site visits to the provider as well as consultation37 TexReg 8000 October 5, 2012 Texas Register
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Texas. Secretary of State. Texas Register, Volume 37, Number 40, Pages 7815-8094, October 5, 2012, periodical, October 5, 2012; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth288982/m1/185/: accessed July 17, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu.; crediting UNT Libraries Government Documents Department.