2023 Tennessee Code › Title 71 - WELFARE (§§ 71-1-101 — 71-7-103) › Chapter 5 - PROGRAMS AND SERVICES FOR POOR PERSONS (§§ 71-5-NEW — 71-5-2604) › Part 25 - TENNCARE FRAUD AND ABUSE (§§ 71-5-2501 — 71-5-2521) › Section 71-5-2503 - Part definitions

As used in this part and part 26 unless the context otherwise requires:
(1)
"Abuse" shall be given the same meaning as currently exists in federal regulations located at
42 CFR 455.2
, with the following exceptions:
(A)
It shall also apply to practices by vendors or other persons or entities; and
(B)
It shall also apply to the TennCare program;
(2)
"Applicant" means any person who has applied for benefits under part 1 of this chapter;
(3)
"Benefits" means the health care package of services available to TennCare enrollees;
(4)
"Claim" includes any request or demand for money, property, or services made to any employee, officer, or agent of the state, or to any contractor, grantee, or other recipient of state funds, whether under contract or not, if any portion of the money, property, or services requested or demanded issued from, or was provided by, TennCare;
(5)
"CMS" (centers for medicare and medicaid services), means the agency within the United States department of health and human services that is responsible for administering Title XVIII (
42 U.S.C. § 1395
et seq.), Title XIX (
42 U.S.C. § 1396
et seq.), and Title XXI (
42 U.S.C. § 1397aa
), of the Social Security Act;
(6)
"Commissioner" means the commissioner of finance and administration;
(7)
"Department" means the department of finance and administration;
(8)
"Enrollee" means an individual eligible for and enrolled in the TennCare program or in any successor medicaid program in Tennessee;
(9)
"Fraud" means an intentional deception or misrepresentation made by a person including, but not limited to, a vendor, recipient, provider, or enrollee, with the knowledge that the deception or misrepresentation could result in some unauthorized benefit or payment to oneself or some other person. It includes any act that constitutes fraud under applicable federal or state law including, but not limited to, the Tennessee Medicaid False Claims Act, compiled in §§
71-5-181
- 71-5-185;
(10)
"Inspector general" means the person who directs the office of inspector general, who shall report directly to the commissioner of finance and administration;
(11)
"Medical assistance" means payment of the cost of care, services and supplies necessary to prevent, diagnose, correct or cure conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with the person's capacity for normal activity, or threaten some significant disability and which are furnished an eligible person in accordance with the rules, regulations, and statutes governing TennCare. Such care, services and supplies includes services of qualified practitioners licensed under the laws of this state;
(12)
"MFCU" means the medicaid fraud control unit;
(13)
"Provider" means an institution, facility, agency, person, corporation, partnership, unincorporated organization, nonprofit organization or any person or entity directly or indirectly providing benefits, goods or services to a TennCare enrollee. Provider also means a provider's agent, contractor or subcontractor, such as a billing agent;
(14)
"Recipient" means any person who has been determined eligible to receive benefits under part 1 of this chapter, and who has received such benefits;
(15)
"TennCare" means the program administered by the single state agency, as designated by the state and CMS, pursuant to Title XIX of the Social Security Act (
42 U.S.C. § 1396
et seq.), and the Section 1115 research and demonstration waiver granted to the state of Tennessee and any successor programs; and
(16)
"Vendor" means any person, institution, agency, other entity or business concern providing services or goods authorized under chapter 5, part 1 of this title, and includes, but is not limited to, any health maintenance organization, managed care organization, managed care contractor, administrative services organization, pharmacy benefit manager, prepaid limited health service organization, contractor or subcontractor.
Acts 2004, ch. 673, § 20; 2005, ch. 474, §§ 8, 16 - 18; 2011, ch. 47, § 106.