Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart B - MEDICAL PROVIDER PARTICIPATION › Section 140.13 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
"Abuse". For purposes of this Part and 89 Ill. Adm. Code 104,
				  "abuse" means provider practices that are inconsistent with sound fiscal,
				  business or medical practices and that result in an unnecessary cost to the
				  Medical Assistance Program or in reimbursement for services that are not
				  medically necessary or that fail to meet professionally recognized standards
				  for health care. It also includes recipient practices that result in
				  unnecessary cost to the Medical Assistance Program. Abuse does not include
				  diagnostic or therapeutic measures conducted primarily as a safeguard against
				  possible vendor liability.
"Alternate Payee". For purposes of this Part, "Alternate
				  Payee" shall mean an entity that is registered as an alternate payee in the
				  Medical Assistance Program. An individual practitioner may designate payments
				  due the practitioner be made to an alternate payee.
"Code". For purposes of this Part, "Code" means the Public
				  Aid Code [305 ILCS 5 ].
"Credible Allegation". For purposes of this Part, "credible
				  allegation" includes an allegation from any source, including, but not limited
				  to, fraud hotline complaints, claims data mining, patterns identified through
				  provider audits, civil actions filed under the False Claims Act [740 ILCS 175
				  ], and law enforcement investigations. An allegation is considered to be
				  credible when it has indicia of reliability.
"Credible Evidence". For purposes of this Part, "credible
				  evidence" shall mean evidence that reasonable people would agree as being
				  trustworthy and reliable.
"Department Policy". For purposes of this Part, "Department
				  policy" shall mean the written requirements of the Department set forth in the
				  Medical Assistance Program Handbooks, and the Department's written manuals,
				  bulletins and releases. It shall also include any additional policy statements
				  transmitted in writing to a vendor.
"Entity". For purposes of this Part, "entity" means any
				  person, firm, corporation, partnership, association, agency, institution, or
				  other legal organization.
"Fraud". For purposes of this Part and 89 Ill. Adm. Code 104,
				  "fraud" means an intentional deception or misrepresentation made by a person
				  with the knowledge that the deception could result in some unauthorized benefit
				  to himself or herself or some other person. It includes any act that
				  constitutes fraud under applicable federal or State law.
"Harm". For purposes of this Part and 89 Ill. Adm. Code 104,
				  "harm" means physical, mental or monetary damage to recipients or to the
				  Medical Assistance Program.
"Investor". For purposes of this Part, "investor" shall mean
				  any entity that owns (directly or indirectly) five percent or more of the
				  shares of stock or other evidences of ownership of a vendor, or holds (directly
				  or indirectly) five percent or more of the debt of a vendor, or owns and holds
				  (directly or indirectly) three percent or more of the combined debt and equity
				  of a vendor.
"Management Responsibility". For purposes of this Part, a
				  person with management responsibility includes a person vested with discretion
				  or judgment who either alone or in conjunction with others, conducts,
				  administers or oversees either the general concerns of the vendor or a portion
				  of the vendor's concerns. A person with management responsibility shall
				  specifically include the pharmacist in a pharmacy, the medical director of a
				  laboratory, the administrator of a hospital or nursing home, the dispatcher in
				  a transportation vendor, dispatchers and all individuals in charge of day to
				  day operations of a non-emergency transportation vendor, the person or persons
				  responsible for preparation and submittal of billings for services to the
				  Department, and the manager of a group practice, clinic or shared health
				  facility.
"Non-Emergency Transportation Vendor". For purposes of this
				  Part, non-emergency transportation vendor shall mean any transportation
				  provider identified in Section
				  140.490(a)
				  other than those identified in Section
				  140.490(a)(1) and
				  (a)(6).
"Technical or Other Advisor". For purposes of this Part,
				  "technical or other advisor" shall mean any entity that provides any form of
				  advice to a vendor regarding the vendor's business or participation in the
				  Medical Assistance Program in return for compensation, directly or indirectly,
				  in any form.
"Vendor". For purposes of this Part, "vendor" or "provider"
				  shall mean a person, firm, corporation, association, agency, institution, or
				  other legal entity that provides goods or services to a recipient or
				  recipients, and is enrolled to participate in the Medical Assistance Program
				  pursuant to 89 Ill. Adm. Code
				  140.11
				  and
				  140.12.
"Waste". For purposes of this Part and 89 Ill. Adm. Code 104,
				  "waste" means the unintentional misuse of medical assistance resources,
				  resulting in unnecessary cost to the Medical Assistance Program. Waste does not
				  include diagnostic or therapeutic measures conducted primarily as a safeguard
				  against possible vendor liability.