Illinois Administrative Code
Title 89 - SOCIAL SERVICES
Part 140 - MEDICAL PAYMENT
Subpart B - MEDICAL PROVIDER PARTICIPATION
Section 140.13 - Definitions
"Abuse". For purposes of this Part and 89 Ill. Adm. Code 104, "abuse" means provider practices that are inconsistent with sound fiscal, business or medical practices and that result in an unnecessary cost to the Medical Assistance Program or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medical Assistance Program. Abuse does not include diagnostic or therapeutic measures conducted primarily as a safeguard against possible vendor liability.
"Alternate Payee". For purposes of this Part, "Alternate Payee" shall mean an entity that is registered as an alternate payee in the Medical Assistance Program. An individual practitioner may designate payments due the practitioner be made to an alternate payee.
"Code". For purposes of this Part, "Code" means the Public Aid Code [305 ILCS 5 ].
"Credible Allegation". For purposes of this Part, "credible allegation" includes an allegation from any source, including, but not limited to, fraud hotline complaints, claims data mining, patterns identified through provider audits, civil actions filed under the False Claims Act [740 ILCS 175 ], and law enforcement investigations. An allegation is considered to be credible when it has indicia of reliability.
"Credible Evidence". For purposes of this Part, "credible evidence" shall mean evidence that reasonable people would agree as being trustworthy and reliable.
"Department Policy". For purposes of this Part, "Department policy" shall mean the written requirements of the Department set forth in the Medical Assistance Program Handbooks, and the Department's written manuals, bulletins and releases. It shall also include any additional policy statements transmitted in writing to a vendor.
"Entity". For purposes of this Part, "entity" means any person, firm, corporation, partnership, association, agency, institution, or other legal organization.
"Fraud". For purposes of this Part and 89 Ill. Adm. Code 104, "fraud" means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or herself or some other person. It includes any act that constitutes fraud under applicable federal or State law.
"Harm". For purposes of this Part and 89 Ill. Adm. Code 104, "harm" means physical, mental or monetary damage to recipients or to the Medical Assistance Program.
"Investor". For purposes of this Part, "investor" shall mean any entity that owns (directly or indirectly) five percent or more of the shares of stock or other evidences of ownership of a vendor, or holds (directly or indirectly) five percent or more of the debt of a vendor, or owns and holds (directly or indirectly) three percent or more of the combined debt and equity of a vendor.
"Management Responsibility". For purposes of this Part, a person with management responsibility includes a person vested with discretion or judgment who either alone or in conjunction with others, conducts, administers or oversees either the general concerns of the vendor or a portion of the vendor's concerns. A person with management responsibility shall specifically include the pharmacist in a pharmacy, the medical director of a laboratory, the administrator of a hospital or nursing home, the dispatcher in a transportation vendor, dispatchers and all individuals in charge of day to day operations of a non-emergency transportation vendor, the person or persons responsible for preparation and submittal of billings for services to the Department, and the manager of a group practice, clinic or shared health facility.
"Non-Emergency Transportation Vendor". For purposes of this Part, non-emergency transportation vendor shall mean any transportation provider identified in Section 140.490(a) other than those identified in Section 140.490(a)(1) and (a)(6).
"Technical or Other Advisor". For purposes of this Part, "technical or other advisor" shall mean any entity that provides any form of advice to a vendor regarding the vendor's business or participation in the Medical Assistance Program in return for compensation, directly or indirectly, in any form.
"Vendor". For purposes of this Part, "vendor" or "provider" shall mean a person, firm, corporation, association, agency, institution, or other legal entity that provides goods or services to a recipient or recipients, and is enrolled to participate in the Medical Assistance Program pursuant to 89 Ill. Adm. Code 140.11 and 140.12.
"Waste". For purposes of this Part and 89 Ill. Adm. Code 104, "waste" means the unintentional misuse of medical assistance resources, resulting in unnecessary cost to the Medical Assistance Program. Waste does not include diagnostic or therapeutic measures conducted primarily as a safeguard against possible vendor liability.
