K.S.A. § 21-5926 — KS Code / Chapter 21 / Article 59 / Section 21-5926
21-5926 - Definitions.
Status: in_force

21-5926. Definitions. As used in the Kansas medicaid fraud control act:

(a) "Aggregate amount of payments illegally claimed" means the greater of: (1) The actual pecuniary harm resulting from the offense; (2) the pecuniary harm that was intended to result from the offense; or (3) the intended pecuniary harm that would have been impossible or unlikely to occur, such as in a government sting operation or a fraud in which the claim exceeded the allowed value. The aggregate dollar amount of fraudulent claims submitted to the medicaid program shall constitute prima facie evidence of the amount of intended loss and is sufficient to establish the aggregate amount of payments illegally claimed, if not rebutted;

(b) "attorney general" means the attorney general, employees of the attorney general or authorized representatives of the attorney general;

(c) "benefit" means the receipt of money, goods, items, facilities, accommodations or anything of pecuniary value;

(d) "claim" means an electronic, electronic impulse, facsimile, magnetic, oral, telephonic or written communication that is utilized to identify any goods, service, item, facility or accommodation as reimbursable to the medicaid program, or its fiscal agents, or which states income or expense and is or may be used to determine a rate of payment by the medicaid program, or its fiscal agent;

(e) "fiscal agent" means any corporation, firm, individual, organization, partnership, professional association or other legal entity which, through a contractual relationship with the Kansas department of health and environment division of health care finance and thereby, the state of Kansas, receives, processes and pays claims under the medicaid program;

(f) "family member" means spouse, child, grandchild of any degree, parent, mother-in-law, father-in-law, grandparent of any degree, brother, brother-in-law, sister, sister-in-law, half-brother, half-sister, uncle, aunt, nephew or niece, whether biological, step or adoptive;

(g) "medicaid program" means the Kansas program of medical assistance for which federal or state moneys, or any combination thereof, are expended as administered by the Kansas department of health and environment division of health care finance, or its fiscal agent, or any successor federal or state, or both, health insurance program or waiver granted thereunder;

(h) "medically necessary" means for the purposes of the Kansas medicaid fraud control act only, any goods, service, item, facility, or accommodation, that a reasonable and prudent provider under similar circumstances would believe is appropriate for diagnosing or treating a recipient's condition, illness or injury;

(i) "pecuniary harm" means harm that is monetary or that otherwise is readily measurable in money, and does not include emotional distress, harm to reputation or other non-economic harm;

(j) "person" means any agency, association, corporation, firm, limited liability company, limited liability partnership, natural person, organization, partnership or other legal entity, the agents, employees, independent contractors, and subcontractors, thereof, and the legal successors thereto, and any official, employee or agent of a state or federal agency having regulatory or administrative authority over the medicaid program;

(k) "provider" means a person who has applied to participate in, who currently participates in, who has previously participated in, who attempts or has attempted to participate in the medicaid program, by providing or claiming to have provided goods, services, items, facilities or accommodations;

(l) "recipient" means an individual, either real or fictitious, in whose behalf any person claimed or received any payment or payments from the medicaid program, or its fiscal agent, whether or not any such individual was eligible for benefits under the medicaid program;

(m) "records" mean all written documents and electronic or magnetic data, including, but not limited to, medical records, X-rays, professional, financial or business records relating to the treatment or care of any recipient; goods, services, items, facilities or accommodations provided to any such recipient; rates paid for such goods, services, items, facilities or accommodations; and goods, services, items, facilities, or accommodations provided to nonmedicaid recipients to verify rates or amounts of goods, services, items, facilities or accommodations provided to medicaid recipients, as well as any records that the medicaid program, or its fiscal agents require providers to maintain;

(n) "sign" means to affix a signature, directly or indirectly, by means of handwriting, typewriter, stamp, computer impulse or other means; and

(o) "statement or representation" means an electronic, electronic impulse, facsimile, magnetic, oral, telephonic, or written communication that is utilized to identify any goods, service, item, facility or accommodation as reimbursable to the medicaid program, or its fiscal agent, or that states income or expense and is or may be used to determine a rate of payment by the medicaid program, or its fiscal agent.