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Texas Statutes (Last Updated: January 4, 2014) |
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HUMAN RESOURCES CODE |
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Title 2. DEPARTMENT OF HUMAN SERVICES AND DEPARTMENT OF PROTECTIVE AND REGULATORY SERVICES |
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Subtitle C. ASSISTANCE PROGRAMS |
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Chapter 36. MEDICAID FRAUD PREVENTION |
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Subchapter A. GENERAL PROVISIONS |
Sec. 36.001. DEFINITIONS
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In this chapter:
(1) "Claim" means a written or electronically submitted request or demand that:
(A) is signed by a provider or a fiscal agent and that identifies a product or service provided or purported to have been provided to a Medicaid recipient as reimbursable under the Medicaid program, without regard to whether the money that is requested or demanded is paid; or
(B) 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 program.
(2) "Documentary material" means a record, document, or other tangible item of any form, including:
(A) a medical document or X ray prepared by a person in relation to the provision or purported provision of a product or service to a Medicaid recipient;
(B) a medical, professional, or business record relating to:
(i) the provision of a product or service to a Medicaid recipient; or
(ii) a rate or amount paid or claimed for a product or service, including a record relating to a product or service provided to a person other than a Medicaid recipient as needed to verify the rate or amount;
(C) a record required to be kept by an agency that regulates health care providers; or
(D) a record necessary to disclose the extent of services a provider furnishes to Medicaid recipients.
(3) "Fiscal agent" means:
(A) a person who, through a contractual relationship with the Texas Department of Human Services, the Texas Department of Health, or another state agency, receives, processes, and pays a claim under the Medicaid program; or
(B) the designated agent of a person described by Paragraph (A).
(4) "Health care practitioner" means a dentist, podiatrist, psychologist, physical therapist, chiropractor, registered nurse, or other provider licensed to provide health care services in this state.
(5) "Managed care organization" has the meaning assigned by Section 32.039(a).
(5-a) "Material" means having a natural tendency to influence or to be capable of influencing.
(6) "Medicaid program" means the state Medicaid program.
(7) "Medicaid recipient" means an individual on whose behalf a person claims or receives a payment from the Medicaid program or a fiscal agent, without regard to whether the individual was eligible for benefits under the Medicaid program.
(7-a) "Obligation" means a duty, whether or not fixed, that arises from:
(A) an express or implied contractual, grantor-grantee, or licensor-licensee relationship;
(B) a fee-based or similar relationship;
(C) a statute or regulation; or
(D) the retention of any overpayment.
(8) "Physician" means a physician licensed to practice medicine in this state.
(9) "Provider" means a person who participates in or who has applied to participate in the Medicaid program as a supplier of a product or service and includes:
(A) a management company that manages, operates, or controls another provider;
(B) a person, including a medical vendor, that provides a product or service to a provider or to a fiscal agent;
(C) an employee of a provider;
(D) a managed care organization; and
(E) a manufacturer or distributor of a product for which the Medicaid program provides reimbursement.
(10) "Service" includes care or treatment of a Medicaid recipient.
(11) "Signed" means to have affixed a signature directly or indirectly by means of handwriting, typewriting, signature stamp, computer impulse, or other means recognized by law.
(12) "Unlawful act" means an act declared to be unlawful under Section 36.002.