Definitions

As used in the Medicaid Provider and Managed Care Act: A. "claim" means a request for payment for services; B. "clean claim" means a claim for reimbursement that: (1) contains substantially all the required data elements necessary for accurate adjudication of the claim without the need for additional information from the medicaid provider or subcontractor; (2) is not materially deficient or improper, including lacking substantiating documentation required by medicaid; and (3) has no particular or unusual circumstances that require special treatment or that prevent payment from being made in due course on behalf of medicaid; C. "credible" means having indicia of reliability after the state has reviewed all allegations, facts and evidence carefully and acted judiciously on a case-by-case basis; D. "credible allegation of fraud" means an allegation that has been verified by the state from any source, including fraud hotline complaints, claims data mining and provider audits; E. "department" or "authority" means the health care authority; F. "fraud" means any act that constitutes fraud under state or federal law; G. "managed care organization" means a person eligible to enter into risk-based prepaid capitation agreements with the authority to provide health care and related services; H. "medicaid" means the medical assistance program established pursuant to Title 19 of the federal Social Security Act and regulations issued pursuant to that act; I. "medicaid provider" means a person that provides medicaid-related services to recipients; J. "overpayment" means an amount paid to a medicaid provider or subcontractor in excess of the medicaid allowable amount, including payment for any claim to which a medicaid provider or subcontractor is not entitled; K. "person" means an individual or other legal entity; L. "recipient" means a person whom the authority has determined to be eligible to receive medicaid-related services; M. "secretary" means the secretary of health care authority; and N. "subcontractor" means a person that contracts with a medicaid provider or a managed care organization to provide medicaid-related services to recipients. History: Laws 1998, ch. 30, § 2; 2019, ch. 215, § 2; 2024, ch. 39, § 117.