2023 Texas Statutes › Penal Code › Title 7 - Offenses Against Property › Chapter 35A - Health Care Fraud › Section 35A.01. Definitions

Sec. 35A.01.  DEFINITIONS.  In this chapter:
(1)  "Claim" means a written or electronically submitted request or demand that:
(A)  is submitted by a provider or the provider's agent and identifies a service or product provided or purported to have been provided to a health care recipient as reimbursable under a health care 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 service or product and is used to determine a rate of payment under a health care program.
(2)  "Fiscal agent" means:
(A)  a person who, through a contractual relationship with a state agency or the federal government, receives, processes, and pays a claim under a health care program; or
(B)  the designated agent of a person described by Paragraph (A).
(3)  "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.
(4)  "Health care program" means a program funded by this state, the federal government, or both and designed to provide health care services to health care recipients, including a program that is administered in whole or in part through a managed care delivery model.
(5)  "Health care recipient" means an individual to whom a service or product is provided or purported to have been provided and with respect to whom a person claims or receives a payment for that service or product from a health care program or fiscal agent, without regard to whether the individual was eligible for benefits under the health care program.
(6)  "Managed care organization" means a person who is authorized or otherwise permitted by law to arrange for or provide a managed care plan.
(7)  "Physician" means a physician licensed to practice medicine in this state.
(8)  "Provider" means a person who participates in or has applied to participate in a health care program as a supplier of a service or product and includes:
(A)  a management company that manages, operates, or controls another provider;
(B)  a person, including a medical vendor, who provides a service or product to another provider or the other provider's agent;
(C)  an employee of the person who participates in or has applied to participate in the program;
(D)  a managed care organization; and
(E)  a manufacturer or distributor of a product for which a health care program provides reimbursement.
(9)  "Service" includes care or treatment of a health care recipient.
(10)  "High managerial agent" means a director, officer, or employee who is authorized to act on behalf of a provider and has duties of such responsibility that the conduct of the director, officer, or employee reasonably may be assumed to represent the policy or intent of the provider.
Added by Acts 2005, 79th Leg., Ch. 806 (S.B. 563), Sec. 16, eff. September 1, 2005.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 620 (S.B. 688), Sec. 8, eff. September 1, 2011.
Acts 2019, 86th Leg., R.S., Ch. 381 (H.B. 2894), Sec. 6, eff. September 1, 2019.