Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-0201 - Definitions

Current through Register Vol. 24-14, July 15, 2024
The definitions in this section and those found in chapter
				  182-500 WAC apply throughout this chapter.
Adverse determination
means a finding of an
				  overpayment identified in a program integrity activity.
Algorithm
means the set of rules applied to
				  claim or encounter data to identify overpayments.
Audit
means an examination of claims data, an
				  entity's records, or both, to determine whether the entity has complied with
				  applicable laws, rules, regulations, and agreements.
Audit, on-site
means an audit conducted
				  partially at an entity's place of business.
Audit, self
means an audit conducted by the
				  entity and reviewed by the agency.
Credible allegation of fraud
- See
				  42
				  C.F.R. 455.2.
Data mining
means using software to detect
				  patterns or aberrancies in a data set.
Educational intervention
means agency-provided
				  education to an entity prior to or following an agency-initiated program
				  integrity activity that has identified an adverse determination. Educational
				  intervention includes, but is not limited to, any notice of adverse
				  determinations issued by the agency or any agency training that has failed to
				  correct the level of payment error.
Encounter
includes any service provided by a
				  federally qualified health center, rural health clinic, or tribe, which is paid
				  an enhanced rate; and any service provided to a Washington apple health client
				  who is covered by an MCO or other contractor, and reported to the
				  agency.
Entity
includes current and former contractors,
				  providers, and their subcontractors.
Extrapolation
means a method of estimating an
				  unknown value by projecting the results of a sample to the universe from which
				  the sample was drawn.
Fraud
- See
				  42
				  C.F.R. 455.2.
Improper payment
means any payment by the agency
				  that was more than or less than the sum to which the payee was legally
				  entitled.
Metrics
mean the quantifiable measures used to
				  track and assess the status of program integrity activities and entity
				  performance.
Net payment error rate
means the calculated
				  percentage of the improper payment amount identified in the sample of claims
				  for the audit period divided by the total payment amount sampled claims for the
				  audit period.
Overpayment
see
				  RCW
				  41.05A.010, including any subsequent
				  amendments.
Program integrity compliance plan
means a
				  document issued by the agency outlining the importance of ethical behavior on
				  the part of the agency's contracted entities, as well as identified monitoring,
				  auditing, and educational obligations an entity must comply with to remain an
				  agency-contracted entity.
Record
means any document or electronically
				  stored information including writings, drawings, graphs, charts, photographs,
				  sound recordings, images, and other data or data compilations, stored in any
				  medium from which information can be obtained either directly or, if necessary,
				  after translation by the entity into a reasonably usable form. This includes
				  documentation relating to claims, encounters, and payments.
Relevant
- See Federal Rule of Evidence
				  401.
Risk assessment
means to identify potential risk
				  of fraud, waste and abuse, and improper payments within all Washington apple
				  health programs.
Sustained high level of payment error
means the
				  net payment error rate is equal to or exceeds five percent for the audit
				  period.
Universe
means a defined population of claims or
				  encounters or both.