Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 13 - Member Rights and Responsibilities › Section 317:35-13-7 - Program Abuse and Administrative Sanctions

Current through Vol. 41, No. 20, July 1, 2024
(a)
Definitions.
The following
				words and terms, when used in this Section, shall have the following meaning,
				unless the context clearly indicates otherwise.
(1) "Abuse" means member actions that defraud
				the Oklahoma Health Care Authority (OHCA), cause unnecessary medical expenses
				to the program or over-utilize services provided by the OHCA. It shall also
				mean causing unnecessary or excessive claims to be submitted to the
				OHCA.
(2) "Conviction" or
				"Convicted" means a judgment of conviction has been entered by a Federal, State
				or local court, regardless of whether an appeal from that judgment is
				pending.
(3) "Exclusion" means not
				being able to be certified for Medicaid benefits under the State Plan or
				Waivered services in Oklahoma.
(4)
				"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 some other person. It includes any act that constitutes fraud
				under applicable Federal or State law.
(5) "Knowingly" means that a person, with
				respect to information:
(A) has actual
				knowledge of the information;
(B)
				acts in deliberate ignorance of the truth or falsity of the information;
				or
(C) acts in reckless disregard
				of the truth or falsity of the information, and no proof of specific intent to
				defraud is required.
(6)
				"Medical Services Providers" means:
(A)
				"Practitioner" means a physician or other individual licensed under State law
				to practice his or her profession or a physician who meets all requirements for
				employment by the Federal Government as a physician and is employed by the
				Federal Government in an IHS facility or affiliated with a 638 Tribal
				facility.
(B) "Supplier" means an
				individual or entity, other than a provider or practitioner, who furnishes
				health care services under Medicaid or other medical services programs
				administered by the OHCA.
(C)
				"Provider" means:
(i) a hospital, skilled
				nursing facility, comprehensive outpatient rehabilitation facility, home health
				agency, or a hospice that has in effect an agreement to participate in
				Medicaid, or any other medical services program administered by the OHCA,
				or
(ii) a clinic, a rehabilitation
				agency, or a public health agency that has a similar agreement.
(D) "Laboratories" means any
				laboratory or place equipped for experimental study in science or for testing
				or analysis which has an agreement with the OHCA to receive Medicaid
				monies.
(E) "Pharmacy" means any
				pharmacy or place where medicines are compounded or dispensed or any pharmacist
				who has an agreement with OHCA to receive Medicaid monies for the dispensing of
				drugs.
(F) "Any other provider"
				means any provider who has an agreement with OHCA to deliver health services,
				medicines, or medical services for the receipt of Medicaid monies.
(7) "OIG" means the Office of
				Inspector General of the Department of Health and Human Services.
(8) "Member" means a beneficiary, patient or
				person served by the OHCA.
(9)
				"Sanctions" means any administrative decision by OHCA to suspend or exclude a
				member from the ability to be certified for medical assistance. A sanction may
				include a decision to use the remedy provided in OAC
				317:30-3-14(b)
				or to require payment by the member of the service.
(10) "Suspension" means an administrative
				action to suspend temporarily the certification of a case for medical
				assistance.
(11) "Willfully" means
				proceeding from a conscious motion of the will; voluntary, intending the result
				which comes to pass; intentional.