Texas Register, Volume 37, Number 40, Pages 7815-8094, October 5, 2012 Page: 8,001
7533-7814 p. ; 28 cm.View a full description of this periodical.
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with expert reviewers, HHS staff subject matter experts, and other state
or federal agencies.
(26) Fraud--Any act that constitutes fraud under applicable
federal or state law, including any intentional deception or misrepresen-
tation made by a person with the knowledge that the deception could
result in some unauthorized benefit to that person or some other person.
Fraud may include any acts prohibited by the Texas Human Resources
Code Chapter 36 or Texas Penal Code Chapter 35A.
(27) Health information--Any information, whether oral or
recorded in any form or medium, that is created or received by a health
care provider, health plan, public health authority, employer, life in-
surer, school or university, or health care clearinghouse, and that relates
to:
(A) the past, present, or future physical or mental health
or condition of an individual;
(B) the provision of health care to an individual; or
(C) the past, present, or future payment for the provi-
sion of health care to an individual.
(28) Health maintenance organization (HMO)--A public or
private organization organized under state law that is a federally quali-
fied HMO or that meets the definition of HMO within this state's Med-
icaid plan.
(29) HHS--Health and human services. Means:
(A) a health and human services agency under the um-
brella of the Commission or its successor, including the Commission;
(B) a program or service provided under the authority
of the Commission, including Medicaid and CHIP; or
(C) a health and human services agency, including
those agencies delineated in Texas Government Code 531.001.
(30) Immediate family member--A person's spouse (hus-
band or wife); natural or adoptive parent; child or sibling; stepparent,
stepchild, stepbrother or stepsister; father-, mother-, daughter-, son-,
brother- or sister-in-law; grandparent or grandchild; or spouse of a
grandparent or grandchild.
(31) Indirect ownership interest--Any ownership interest in
an entity that has an ownership interest in another entity. The term in-
cludes an ownership interest in any entity that has an indirect ownership
interest in the entity at issue.
(32) Inducement--An attempt to entice or lure an action on
the part of another in exchange for, without limitation, cash in any
amount, entertainment, any item of value, a promise, specific perfor-
mance, or other consideration.
(33) Knew or should have known--A person, with respect
to information, knew or should have known when a person had or
should have had actual knowledge of information, acted in deliberate
ignorance of the truth or falsity of the information, or acted in reckless
disregard of the truth or falsity of the information. Proof of a person's
specific intent to commit a program violation is not required in an ad-
ministrative proceeding to show that a person acted knowingly.
(34) Managed care plan--A plan under which a person un-
dertakes to provide, arrange for, pay for, or reimburse, in whole or in
part, the cost of any health care service. A part of the plan must con-
sist of arranging for or providing health care services as distinguished
from indemnification against the cost of those services on a prepaid
basis through insurance or otherwise. The term does not include an in-
surance plan that indemnifies an individual for the cost of health care
services.(35) Managing employee--An individual, regardless of the
person's title, including a general manager, business manager, admin-
istrator, officer, or director, who exercises operational or managerial
control over the employing entity, or who directly or indirectly con-
ducts the day-to-day operations of the entity.
(36) MCO--Managed care organization. Has the meaning
described in 353.2 of this title (relating to Definitions), and for pur-
poses of this chapter includes an MCO's special investigative unit un-
der Texas Government Code 531.113(a)(1), and any entity with which
the MCO contracts for investigative services under Texas Government
Code 531.113(a)(2).
(37) MCO provider--An association, group, or individual
health care provider furnishing services to MCO members under con-
tract with an MCO.
(38) Medicaid or Medicaid program--The Texas medical
assistance program established under Human Resources Code, Chapter
32 and regulated in part under Title 42 CFR Part 400 or its successor.
(39) Medicaid-related funds--Any funds that:
(A) a provider obtains or has access to by virtue of par-
ticipation in Medicaid; or
(B) a person obtains through embezzlement, misuse,
misapplication, improper withholding, conversion or misappropriation
of funds that had been obtained by virtue of participation in Medicaid.
(40) Medicaid Provider Integrity Division (MPI)--The di-
vision within OIG that investigates provider or contractor fraud and
abuse in Medicaid and other HHS programs or its successor.
(41) Medical assistance--Includes all of the health care and
related services and benefits authorized or provided under state or fed-
eral law for eligible individuals of this state.
(42) Member of household--An individual who is sharing
a common abode as part of a single-family unit, including domestic
employees, partners, and others who live together as a family unit.
(43) MFCU--The Medicaid Fraud Control Unit of the
Texas Office of the Attorney General or its successor.
(44) OAG--Office of the Attorney General of Texas or its
successor.
(45) OIG--Office of the Inspector General or its successor.
The office within the Commission responsible for:
(A) the investigation of fraud, abuse, and waste;
(B) ensuring program integrity within the Medicaid
program and other health and human services provided by the state;
and
(C) the enforcement of state law relating to the provi-
sion of those services.
(46) OMB--The Federal Office of Management and Bud-
get or its successor.
(47) Operating agency--A state agency that operates any
part of the Medicaid or other HHS program.
(48) Overpayment--The amount paid by Medicaid or other
HHS program or the amount collected or received by a person by virtue
of the provider's participation in Medicaid or other HHS program that
exceeds the amount to which the provider or person is entitled under
1902 of the Social Security Act or other state or federal statutes for a
service or item furnished within the Medicaid or other HHS programs.
This includes:ADOPTED RULES October 5, 2012 37 TexReg 8001
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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/m1/186/: accessed July 17, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.