California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 1.5 - Provider Audit Appeals › Section 51016 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The following
					 definitions shall be used throughout this article unless otherwise noted.
(1) Audits or Examination Report. "Audit or
					 examination report" means a document that presents the final audit or
					 examination findings and is formally issued to the provider by the Department
					 upon the completion of the audit or examination.
(2) Completed Audit or Examination.
					 "Completed audit or examination" means an audit or examination for which an
					 audit or examination report has been issued.
(3) "Date of mailing" means the date
					 postmarked on the envelope if postage was prepaid and the envelope was properly
					 addressed.
(4) Demand for
					 Repayment. "Demand for repayment" means a written notice issued to the provider
					 by the Department that identifies the amount of the overpayment, determined by
					 an audit or examination, that must be repaid. The notice may be made through
					 the issuance of a statement of accountability, statement of account status,
					 letter, or any combination of the foregoing.
(5) Duplicate. "Duplicate" means a
					 counterpart or facsimile copy of the original produced by the same impression
					 or from the same matrix as the original or by some technique of accurate
					 reproduction.
(6) "Exit conference"
					 means an informal meeting, between the provider and those Department
					 representatives responsible for the audit or examination, at which the
					 preliminary findings of the audit or examination are discussed.
(7) Formal Hearing. "Formal hearing" means an
					 administrative hearing conducted by a hearing officer pursuant to Section
					 14171(b),
					 Welfare and Institutions Code, and the provisions of this article.
(8) Hearing Auditor. "Hearing auditor" means
					 an individual designated to conduct the informal level of review.
(9) Hearing Officer. "Hearing officer" means
					 a hearing officer appointed by the Director pursuant to Section
					 14171(b),
					 Welfare and Institutions Code.
(10)
					 Informal Conference. "Informal conference" means a proceeding conducted in
					 person or by telephone, for the purpose of scheduling the informal level of
					 review and formal hearing; exchanging documents; and resolving other
					 preliminary matters.
(11) Informal
					 Level of Review. "Informal level of review" means an informal hearing for
					 institutional providers and a pretrial conference for non-institutional
					 providers, held by a hearing officer or hearing auditor prior to a formal
					 hearing to clarify or resolve facts and issues in dispute.
(12) Party. "Party" means the provider, the
					 Department and any person, other than a hearing officer, allowed to appear in
					 the proceedings.
(13) Institutional
					 Provider. "Institutional provider" means any of the following:
(A) Any individual, entity or organization of
					 a type required to be licensed pursuant to either Chapter 1 (commencing with
					 Section 1200) or Chapter 2 (commencing
					 with Section
					 1250) of Division 2, Health and
					 Safety Code, or exempt from licensure pursuant to Section
					 1206(b) through
					 (
l
) Health and Safety Code, or Section
					 1254 Health and Safety Code which
					 provides services or supplies under the Medi-Cal program, and is subject to
					 audit by the Department.
(B) Any
					 individual, entity, or organization of a type required to file a cost report or
					 cost information with the Department.
(14) Non-institutional Provider.
					 "Non-institutional provider" means any individual, entity, or organization
					 other than those defined in subsection (13) who provides services or supplies
					 under the Medi-Cal program, and who is subject to audit by the
					 Department.
(15) File. "File" means
					 delivery of a pleading or other paper to, and its date stamping by, the Office
					 of Administrative Hearings and Appeals, Office of Legal Services, Department of
					 Health Services.
(16) Serve.
					 "Serve" means the delivery of a pleading or other paper on a party in the
					 manner provided by Government Code Section
					 11505(c).