2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 36 - Health Care Program Fraud Prevention › Subchapter A. General Provisions › Section 36.001. Definitions

Sec. 36.001.  DEFINITIONS.  In this chapter:
(1)  "Child health plan program" means the child health plan program established under Chapters 62 and 63, Health and Safety Code.
(1-a)  "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 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 product or a service and that is used to determine a rate of payment under a health care 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 health care recipient;
(B)  a medical, professional, or business record relating to:
(i)  the provision of a product or service to a health care 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 health care 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 health care recipients.
(3)  "Fiscal agent" means:
(A)  a person who, through a contractual relationship with a state agency, receives, processes, and pays a claim under a health care 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.
(4-a)  "Health care program" means:
(A)  the Medicaid program;
(B)  the child health plan program; and
(C)  the Healthy Texas Women program.
(4-b)  "Health care recipient" means an individual on whose behalf a person claims or receives a payment from a health care program or a fiscal agent, without regard to whether the individual was eligible for benefits under the health care program.
(4-c)  "Healthy Texas Women program" means a program operated by the commission that is substantially similar to the demonstration project operated under former Section 32.0248 and that is intended to expand access to preventive health and family planning services for women in this state.
(5)  "Managed care organization" means a person who is authorized or otherwise permitted by law to arrange for or provide a managed care plan.
(5-a)  "Material" means having a natural tendency to influence or to be capable of influencing.
(6)  Repealed by Acts 2023, 88th Leg., R.S., Ch. 273 (S.B. 745), Sec. 12, eff. September 1, 2023.
(7)  Repealed by Acts 2023, 88th Leg., R.S., Ch. 273 (S.B. 745), Sec. 12, eff. September 1, 2023.
(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 a health care 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 a health care program provides reimbursement.
(10)  "Service" includes care or treatment of a health care 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.
Added by Acts 1995, 74th Leg., ch. 824, Sec. 1, eff. Sept. 1, 1995.  Amended by Acts 1997, 75th Leg., ch. 1153, Sec. 4.02, eff. Sept. 1, 1997.
Amended by:
Acts 2005, 79th Leg., Ch. 806 (S.B. 563), Sec. 1, eff. September 1, 2005.
Acts 2011, 82nd Leg., R.S., Ch. 398 (S.B. 544), Sec. 1, eff. September 1, 2011.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.179, eff. April 2, 2015.
Acts 2023, 88th Leg., R.S., Ch. 273 (S.B. 745), Sec. 3, eff. September 1, 2023.
Acts 2023, 88th Leg., R.S., Ch. 273 (S.B. 745), Sec. 12, eff. September 1, 2023.