Idaho Administrative Code
Title IDAPA 16 - Health and Welfare, Department of
Rule 16.05.07 - THE INVESTIGATION AND ENFORCEMENT OF FRAUD, ABUSE, AND MISCONDUCT
Section 16.05.07.010 - DEFINITIONS
Current through August 31, 2023
For purposes of this chapter of rules, the following terms apply. (3-17-22)
01. Abuse or Abusive. Provider practices that are inconsistent with sound fiscal, business, child care, or medical practices, and result in an unnecessary cost to a public assistance program, in reimbursement for services that are not medically necessary, or that fail to meet professionally recognized standards for health care, or in physical harm, pain, or mental anguish to a medical assistance recipient. (3-17-22)
02. Access to Documentation and Records. To review and copy records at the time a written request is made during normal business hours. Documentation includes all materials as described in Section 101 of these rules. (3-17-22)
03. Claim. Any request or demand for payment, or document submitted to initiate payment, for items or services provided under a public assistance program, whether under a contract or otherwise. (3-17-22)
04. Conviction. An individual or entity is considered to have been convicted of a criminal offense: (3-17-22)
05. Department. The Idaho Department of Health and Welfare, its authorized agent or designee. (3-17-22)
06. Director. The Director of the Idaho Department of Health and Welfare or the Director's designee. (3-17-22)
07. Exclusion. A specific person or provider will be precluded from directly or indirectly providing services and receiving reimbursement under Medicaid. (3-17-22)
08. Fraud or Fraudulent. 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. (3-17-22)
09. Knowingly, Known, or with Knowledge. A person, with respect to information or an action, who: (3-17-22)
10. Managing Employee. A general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency. (3-17-22)
11. Medicaid. Idaho's Medical Assistance Program. (3-17-22)
12. Medical Assistance. Payments for part or all of the cost of services funded by Titles XIX or XXI of the federal Social Security Act, as amended. (3-17-22)
13. Misconduct. Wrongful, improper, or unlawful conduct related to public assistance rules and programs, including violations of rules, statutes, provider agreements and terms, provider handbooks, and any instructions contained in provider information releases or other program notices. (3-17-22)
14. Participant. An individual or recipient who is eligible and enrolled in any public assistance program. (3-17-22)
15. Person. An individual, trust or estate, partnership, corporation, professional association or corporation, or other entity, public or private. (3-17-22)
16. Program. Any public assistance program, including the Medicaid program and Idaho's State Plan, or any parts thereof. (3-17-22)
17. Provider. An individual, organization, agency, or other entity providing items or services under a public assistance program. (3-17-22)
18. Provider Agreement. A written agreement between the Department and a provider or group of providers of supplies or services. This agreement contains any terms or conditions deemed appropriate by the Department. (3-17-22)
19. Public Assistance Program. Assistance for which provision is made in any federal or state law existing, or hereafter enacted, by the state of Idaho or the congress of the United States by which payments are made from the federal government to the state in aid, or in respect to payment by the state for welfare purposes to any category of needy person, and any other program of assistance for which provision for federal or state funds for aid may from time to time be made. (3-17-22)
20. Recoup and Recoupment. The collection of funds for the purpose of recovering overpayments made to providers for items or services the Department has determined should not have been paid. The recoupment may occur through the collection of future claims paid or other means. (3-17-22)
21. Sanction. Any abatement or corrective action taken by the Department which is appealable under Section 003 of these rules. (3-17-22)
22. State Plan. The contract between the state and federal government under 42 U.S.C. Section 1396a(a). (3-17-22)
