53-6-1401. Definitions. As used in this part, unless expressly provided otherwise, the following definitions apply:

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(1)”Abuse” means conduct by a provider or other person involving disregard of and an unreasonable failure to conform with the statutes, regulations, and rules governing the medical assistance program when the disregard or failure results or may result in medical assistance payments to which the provider is not entitled.

(2)”Auditor” means an individual or an entity, its agents, subcontractors, and employees that have contracted with the department to perform overpayment audits with respect to the medicaid program. The term includes a recovery audit contractor.

(3)”Automated review” means a claim review that is made at the system level without a human being reviewing the medical record.

(4)”Claim” means a communication, whether in oral, written, electronic, magnetic, or other form, that is used to claim specific services or items as payable or reimbursable under the medicaid program. The term includes any documents submitted as part of or in support of the claim.

(5)”Department” means the department of public health and human services provided for in 2-15-2201.

(6)”Document” means an application, claim, form, report, record, writing, or correspondence, whether in written, electronic, magnetic, or other form.

(7)”Extrapolation” means the determination of an unknown value by projecting the results of a review of a sample to the universe from which the sample was drawn.

(8)”Followup audit” means a followup overpayment audit of additional claims data or provider records or both for a particular service code reviewed in an initial overpayment audit after an initial audit has demonstrated a significant error rate with respect to the code to determine whether the provider has complied with applicable medicaid rules, regulations, policies, and agreements.

(9)”Fraud” means conduct or activity prohibited by statute, regulation, or rule involving purposeful or knowing conduct or omission to perform a duty that results in or may result in medicaid payments to which a provider is not entitled. Fraud includes but is not limited to any conduct or omission under the medicaid program that would constitute a criminal offense under Title 45, chapter 6 or 7.

(10)”High-risk provider” means a provider who within the previous 6 years and 3 months:

(a)has either admitted to medicaid fraud or abuse in a written agreement with a governmental agency or has been determined by a final order or judgment of a governmental agency or court to have committed medicaid fraud or abuse; or

(b)has a documented history of a significant error rate that has been sustained over a period of at least 2 years and that multiple documented educational interventions have failed to correct.

(11)”Initial audit” means an initial overpayment audit to examine claims data and provider records or both to determine whether the provider has complied with applicable medicaid rules, regulations, policies, and agreements.

(12)”Medicaid” means the Montana medical assistance program established under Title 53, chapter 6.

(13)(a) “Overpayment audit” means a review or audit by the department or an auditor of claims data, medical claims, or other documents in which a purpose or potential result of the review or audit is an overpayment determination. The term includes an initial audit and a followup audit.

(b)The term does not include a review or audit by the medicaid fraud control unit.

(14)”Overpayment determination” means a determination by the department or an auditor that forms the basis for or results in the department:

(a)partially or completely reducing a medicaid payment to a provider for a claim;

(b)demanding that the provider repay all or a part of a payment for a claim; or

(c)using or applying any other method to recoup, recover, or collect from a provider all or part of a payment for a claim.

(15)”Peer” means a health care provider who is employed by or under contract with the department or an auditor and who:

(a)has substantially the same education and training, provides or has provided substantially the same range of health care services, and has the same license to practice as the provider who is the subject of an overpayment audit; or

(b)is an expert in the medical, dental, mental health, behavioral health, or other health care provider decisionmaking that is at issue in the overpayment audit.

(16)”Provider” means an individual, company, partnership, corporation, institution, facility, or other entity or business association that has enrolled or applied to enroll as a provider of services or items under the medical assistance program established under this chapter.

(17)(a) “Records” means medical, professional, business, or financial information and documents, whether in written, electronic, magnetic, microfilm, or other form:

(i)pertaining to the provision of treatment, care, services, or items to an individual receiving services under the medicaid program;

(ii)pertaining to the income and expenses of the provider; or

(iii)otherwise relating to or pertaining to a determination of eligibility for or entitlement to payment or reimbursement under the medicaid program.

(b)The term includes all such records and documents made and maintained by the provider regardless of whether the records are required by medicaid laws, regulations, rules, or policies.

(18)”Recovery audit contractor” means a medicaid recovery audit contractor selected by the department to perform audits for the purpose of ensuring medicaid program integrity in accordance with 42 CFR, part 455.

(19)”Significant error rate” means previous billing errors greater than 5% of the total lines reviewed.