The following words and terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise:
  (1) Abuse--A practice by a provider that is inconsistent with sound fiscal, business, or medical practices and that results in an unnecessary cost to the Medicaid program; the reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care; or a practice by a recipient that results in an unnecessary cost to the Medicaid program.
  (2) Address of record--
    (A) An HHS provider's current mailing or physical address, including a working fax number, as provided to the appropriate HHS program's claims administrator or as required by contract, statute, or regulation; or
    (B) a non-HHS provider's last known address as reflected by the records of the United States Postal Service or the Texas Secretary of State's records for business organizations, if applicable.
  (3) Affiliate; affiliate relationship--A person who:
    (A) has a direct or indirect ownership interest (or any combination thereof) of five percent or more in the person;
    (B) is the owner of a whole or part interest in any mortgage, deed of trust, note or other obligation secured (in whole or in part) by the entity whose interest is equal to or exceeds five percent of the value of the property or assets of the person;
    (C) is an officer or director of the person, if the person is a corporation;
    (D) is a partner of the person, if the person is organized as a partnership;
    (E) is an agent or consultant of the person;
    (F) is a consultant of the person and can control or be controlled by the person or a third party can control both the person and the consultant;
    (G) is a managing employee of the person, that is, a person (including a general manager, business manager, administrator or director) who exercises operational or managerial control over a person or part thereof, or directly or indirectly conducts the day-to-day operations of the person or part thereof;
    (H) has financial, managerial, or administrative influence over the operational decisions of a person;
    (I) shares any identifying information with another person, including tax identification numbers, social security numbers, bank accounts, telephone numbers, business addresses, national provider numbers, Texas provider numbers, and corporate or franchise names; or
    (J) has a former relationship with another person as described in subparagraphs (A) - (I) of this definition, but is no longer described, because of a transfer of ownership or control interest to an immediate family member or a member of the person's household of this section within the previous five years if the transfer occurred after the affiliate received notice of an audit, review, investigation, or potential adverse action, sanction, board order, or other civil, criminal, or administrative liability.
  (4) Agent--Any person, company, firm, corporation, employee, independent contractor, or other entity or association legally acting for or in the place of another person or entity.
  (5) Allegation of fraud--Allegation of Medicaid fraud received by HHSC from any source that has not been verified by the 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.
  (6) Applicant--An individual or an entity that has filed an enrollment application to become a provider, re-enroll as a provider, or enroll a new practice location in a Medicaid program or the Children's Health Insurance Program as described in subsection (23) of this section.
  (7) At the time of the request--Immediately upon request and without delay.
  (8) Audit--A financial audit, attestation engagement, performance audit, compliance audit, economy and efficiency audit, effectiveness audit, special audit, agreed-upon procedure, nonaudit service, or review conducted by or on behalf of the state or federal government. An audit may or may not include site visits to the provider's place of business.
  (9) Auditor--The qualified person, persons, or entity performing the audit on behalf of the state or federal government.
  (10) Business day--A day that is not a Saturday, Sunday, or state legal holiday. In computing a period of business days, the first day is excluded and the last day is included. If the last day of any period is a Saturday, Sunday, or state legal holiday, the period is extended to include the next day that is not a Saturday, Sunday, or state legal holiday.
  (11) C.F.R.--The Code of Federal Regulations.
  (12) CHIP--The Texas Children's Health Insurance Program or its successor, established under Title XXI of the federal Social Security Act (42 U.S.C. §§1397aa et seq.) and Chapter 62 of the Texas Health and Safety Code.
  (13) Claim--
    (A) A written or electronic application, request, or demand for payment by the Medicaid or other HHS program for health care services or items; or
    (B) A submitted request, demand, or representation that states the income earned or expense incurred by a provider in providing a product or a service and that is used to determine a rate of payment under the Medicaid or other HHS program.
  (14) Claims administrator--The entity an operating agency has designated to process and pay Medicaid or HHS program provider claims.
  (15) Closed-end contract--A contract or provider agreement for a specific period of time. It may include any specific requirements or provisions deemed necessary by the OIG to ensure the protection of the program. It must be renewed for the provider to continue to participate in the Medicaid or other HHS program.
  (16) CMS--The Centers for Medicare & Medicaid Services or its successor. CMS is the federal agency responsible for administering Medicare and overseeing state administration of Medicaid and CHIP.
  (17) Complete Application--A provider enrollment application that contains all the required information, including:
    (A) all questions answered completely, including correct dates of birth, social security numbers, license numbers, and all requirements per provider type defined in the Texas Medicaid Provider Procedures Manual;
    (B) IRS Form W-9, if required;
    (C) signed and certified provider agreements;
    (D) Provider Information Form (PIF-1);
    (E) Principal Information Forms (PIF-2) on all persons required to be disclosed, if required;
    (F) full disclosure of all criminal history, including copies of complete dispositions on all criminal history;
    (G) full disclosure of all board or licensing orders, including documentation of compliance with current board orders;
    (H) full disclosure of all corporate compliance agreements, settlement agreements, state or federal debt, and sanctions;
    (I) documentation of an active license that is not subject to expiration within 30 days of submission of the enrollment application, if required;
    (J) completion of a pre-enrollment site visit by HHSC, if required, and all required current documentation (e.g., liability insurance);
    (K) documentation of fingerprints of a provider or any person with a five percent or more direct or indirect ownership in the provider, if required; and
    (L) any additional documentation related to the addition of a practice location, if required or requested by HHSC.
  (18) Conviction or convicted--Means that:
    (A) a judgment of conviction has been entered against an individual or entity by a federal, state, or local court, regardless of whether:
      (i) there is a post-trial motion or an appeal pending; or
      (ii) the judgment of conviction or other record relating to the criminal conduct has been expunged or otherwise removed;
    (B) a federal, state, or local court has made a finding of guilt against an individual or entity;
    (C) a federal, state, or local court has accepted a plea of guilty or nolo contendere by an individual or entity; or
    (D) an individual or entity has entered into participation in a first offender, deferred adjudication, pre-trial diversion, or other program or arrangement where judgment of conviction has been withheld.
Cont'd...