Texas § GV.544.0001 - DEFINITIONS

§ GV.544.0001. DEFINITIONS

DEFINITIONS. In this chapter: (1) "Abuse" means: (A) a practice a provider engages in that is inconsistent with sound fiscal, business, or medical practices and that results in: (i) an unnecessary cost to Medicaid; or (ii) reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care; or (B) a practice a recipient engages in that results in an unnecessary cost to Medicaid. (2) "Allegation of fraud" means an allegation of Medicaid fraud the commission receives from any source that has not been verified by this state, including an allegation based on: (A) a fraud hotline complaint; (B) claims data mining; (C) data analysis processes; or (D) a pattern identified through provider audits, civil false claims cases, or law enforcement investigations. (3) "Credible allegation of fraud" means an allegation of fraud that has been verified by this state. An allegation is considered credible when the commission has: (A) verified that the allegation has indicia of reliability; and (B) carefully reviewed all allegations, facts, and evidence and acts judiciously on a case-by-case basis. (4) "Fraud" means an intentional deception or misrepresentation a person makes with the knowledge that the deception or misrepresentation could result in an unauthorized benefit to that person or another person. The term does not include unintentional technical, clerical, or administrative errors. (5) "Furnished" refers to the provision of items or services directly by or under the direct supervision of, or the ordering of items or services by: (A) a practitioner or other individual acting as an employee or in the individual's own capacity; (B) a provider; or (C) another supplier of services, excluding services ordered by one party but billed for and provided by or under the supervision of another. (6) "Inspector general" means the inspector general the governor appoints under Section 544.0101 . (7) "Office of inspector general" means the commission's office of inspector general. (8) "Payment hold" means the temporary denial of Medicaid reimbursement for items or services a specified provider furnished. (9) "Physician" includes: (A) an individual licensed to practice medicine in this state; (B) a professional association composed solely of physicians; (C) a partnership composed solely of physicians; (D) a single legal entity authorized to practice medicine that is owned by two or more physicians; and (E) a nonprofit health corporation certified by the Texas Medical Board under Chapter 162 , Occupations Code. (10) "Practitioner" means a physician or other individual licensed under state law to practice the individual's profession. (11) "Program exclusion" means the suspension of a provider's authorization under Medicaid to request reimbursement for items or services the provider furnished. (12) "Provider" means, except as otherwise provided by this chapter, a person that was or is approved by the commission to: (A) provide Medicaid services under a contract or provider agreement with the commission; or (B) provide third-party billing vendor services under a contract or provider agreement with the commission. Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611 ), Sec. 1.01, eff. April 1, 2025.