Texas Register, Volume 37, Number 40, Pages 7815-8094, October 5, 2012 Page: 8,002
7533-7814 p. ; 28 cm.View a full description of this periodical.
Extracted Text
The following text was automatically extracted from the image on this page using optical character recognition software:
(A) any funds collected or received in excess of the
amount to which the provider is entitled, whether obtained through er-
ror, misunderstanding, abuse, misapplication, misuse, embezzlement,
or improper retention or fraud;
(B) recipient trust funds and funds collected by a person
from recipients if collection was not allowed by Medicaid or other HHS
program policy; or
(C) questioned costs identified in a final audit report that
found that claims or cost reports submitted in error resulted in money
paid in excess of what the provider is entitled to under an HHS program,
contract, or grant.
(49) Ownership interest--A direct or indirect ownership in-
terest (or any combination thereof) of 5% or more in the equity in the
capital, the stock, the profits, or other assets of a person or any mort-
gage, deed, trust or note, or other obligation secured in whole or in part
by the property or assets of the person.
(50) Payment hold (suspension of payments)--An admin-
istrative sanction that withholds all or any portion of payments due a
provider until the matter in dispute, including all investigation and legal
proceedings, between the provider and the Commission or an operat-
ing agency or its agent(s) are resolved. This is a temporary denial of
reimbursement under the Medicaid or other HHS program for items or
services furnished by a specified provider.
(51) Person--Any legally cognizable entity, including an
individual, firm, association, partnership, limited partnership, corpo-
ration, agency, institution, MCO, Special Investigative Unit, CHIP
participant, trust, non-profit organization, special-purpose corporation,
limited liability company, professional entity, professional association,
professional corporation, accountable care organization, or other
organization or legal entity.
(52) Person with a disability--An individual with a mental,
physical, or developmental disability that substantially impairs the in-
dividual's ability to provide adequately for the person's care or his or
her own protection, and:
(A) who is 18 years of age or older; or
(B) who is under 18 years of age and who has had the
disabilities of minority removed.
(53) Practitioner--A physician or other individual licensed
or certified under state law to practice their profession.
(54) Prima facie--Sufficient to establish a fact or raise a
presumption unless disproved.
(55) Probationary contract--A contract or provider agree-
ment for any period of time. It may include any special requirements
or provisions deemed necessary by OIG to ensure the protection of the
program. It must be renewed by OIG for the provider to continue to par-
ticipate in the program. It may also be referred to as a provisional con-
tract, depending upon the terminology used by the provider's agency
and program area.
(56) Professionally recognized standards of health care--
Statewide or national standards of care, whether in writing or not, that
professional peers of the individual or entity whose provision of care is
an issue, recognize as applying to those peers practicing or providing
care within the state of Texas.
(57) Program violation--A failure to comply with a Med-
icaid or other HHS provider contract or agreement, the Texas Med-
icaid Provider Procedures Manual or other official program publica-
tions, or any state or federal statute, rule, or regulation applicable to
the Medicaid or other HHS program, including any action that con-stitutes grounds for enforcement as delineated in this subchapter that
forms the basis for an investigation, audit, or other review or that re-
sults in a notice of potential or final adverse action for cause.
(58) Provider--Any person, including an MCO and its sub-
contractors, that:
(A) is furnishing Medicaid or other HHS services under
a provider agreement or contract in force with a Medicaid or other HHS
operating agency;
(B) has a provider or contract number issued by the
Commission or by any HHS agency or program or their designee to
provide medical assistance, Medicaid, or any other HHS service in any
HHS program, including CHIP, under contract or provider agreement
with the Commission, its designee, or an HHS agency; or
(C) provides third-party billing services under a con-
tract or provider agreement with the Commission or its designee.
(59) Provider agreement--A contract, including any and all
amendments and updates, with Medicaid or other HHS program to sub-
contract services, or with an MCO to provide services.
(60) Provider screening process--The process that a person
participates in to become eligible to participate and enroll as a provider
in Medicaid or other HHS program. This process includes enrollment
under this chapter, 42 CFR Part 1001, or other processes delineated by
statute, rule or regulation.
(61) Provisional contract--A contract or provider agree-
ment for any period of time. It may include any special requirements
or provisions deemed necessary by OIG to ensure the protection of the
program. It must be renewed by OIG for the provider to continue to
participate in the program. It may also be referred to as a probationary
contract, depending upon the terminology used by the provider's
agency and program area.
(62) Reasonable request--Request for access, records, doc-
umentation or other items deemed necessary or appropriate by OIG or
a Requesting Agency to perform an official function, and made by a
properly identified agent of OIG or a Requesting Agency during hours
that a person, business, or premises is open for business.
(63) Recipient--A person eligible for and covered by the
Medicaid or any other HHS program.
(64) Records and documentation--Records and documents
in any form, including electronic form, which include:
(A) medical records, charting, other records pertaining
to a patient, radiographs, laboratory and test results, molds, models,
photographs, hospital and surgical records, prescriptions, patient or
client assessment forms, and other documents related to diagnosis,
treatment or service of patients;
(B) billing and claims records, supporting documenta-
tion such as Title XIX forms, delivery receipts, and any other records of
services provided to recipients and payments made for those services;
(C) cost reports, documentation supporting cost re-
ports;
(D) managed care encounter data, financial data neces-
sary to demonstrate solvency of risk-bearing providers;
(E) ownership disclosure statements, articles of incor-
poration, bylaws, corporate minutes, or other documentation demon-
strating ownership of corporate entities;
(F) business and accounting records, business and ac-
counting support documentation;37 TexReg 8002 October 5, 2012 Texas Register
Upcoming Pages
Here’s what’s next.
Search Inside
This issue can be searched. Note: Results may vary based on the legibility of text within the document.
Tools / Downloads
Get a copy of this page or view the extracted text.
Citing and Sharing
Basic information for referencing this web page. We also provide extended guidance on usage rights, references, copying or embedding.
Reference the current page of this Periodical.
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/m1/187/: accessed July 17, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu.; crediting UNT Libraries Government Documents Department.