Utah Administrative Code
Topic - Health
Title R414 - Integrated Healthcare
Rule R414-22 - Administrative Sanction Procedures and Regulations
Section R414-22-2 - Definitions
Current through Bulletin 2024-06, March 15, 2024
The definitions in Rule R414-1 apply to this rule. In addition:
(1) "Abuse" means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in reimbursement for services that are either not medically necessary or fail to meet professionally recognized standards for health care.
(2) "Conviction" or "convicted" means a criminal conviction entered by a federal or state court for fraud involving Medicare or Medicaid regardless of whether an appeal from judgment is pending.
(3) "Fiscal agent" means an organization that processes and pays provider claims on behalf of the department.
(4) "Fraud" means intentional deception or misrepresentation made by a person that results in some unauthorized Medicaid benefit to the person or someone else. It includes any act that constitutes fraud under applicable state law.
(5) "Member" means an individual who is determined eligible for Medicaid.
(6) "Offense" means any of the grounds for sanctioning set forth in Section R414-22-4.
(7) "Person" means any natural person, company, firm, association, corporation, or other legal entity.
(8) "Practitioner" means a physician or other individual licensed under state law to practice their profession.
(9) "Provider" means an individual or other entity approved by the department to provide services to Medicaid members that has signed a provider agreement with the department.
(10) "Provider Sanction Committee" means the committee within the department that determines whether a Medicaid provider with a conviction or other sanction identified in Subsection R414-22-3 (3), (4), or (5) may enroll or remain in the Medicaid program. This committee consists of a designee of the Executive Director of the department, a designee of the Office of Inspector General of Medicaid Services (OIG), and the office director over provider enrollment.
(11) "Suspension" means a status in which the Division of Professional Licensing (DOPL) or an equivalent entity in another state classifies a provider, which results in the department not adjudicating or reimbursing claims submitted by that provider.
(12) "Termination from participation" means termination of the existing provider agreement.
