Utah Code 63A-13-205. Placement of hold on claims for reimbursement — Injunction
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(1) The inspector general or the inspector general’s designee may, without prior notice, order a hold on the payment of a claim for reimbursement submitted by a claimant if there is reasonable cause to believe that the claim, or payment of the claim, constitutes fraud, waste, or abuse, or is otherwise inaccurate.
Terms Used In Utah Code 63A-13-205
- Abuse: means :(1)(a) an action or practice that:(1)(a)(i) is inconsistent with sound fiscal, business, or medical practices; and(1)(a)(ii) results, or may result, in unnecessary Medicaid related costs; or(1)(b) reckless or negligent upcoding. See Utah Code 63A-13-102
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Claimant: means a person that:
(2)(a) provides a service; and(2)(b) submits a claim for Medicaid reimbursement for the service. See Utah Code 63A-13-102- Department: means the Department of Health and Human Services created in Section 26B-1-201. See Utah Code 63A-13-102
- Division: means the Division of Integrated Healthcare, created in Section 26B-3-102. See Utah Code 63A-13-102
- Fraud: Intentional deception resulting in injury to another.
- Fraud: means an intentional or knowing:
(6)(a) deception, misrepresentation, or upcoding in relation to Medicaid funds, costs, a claim, reimbursement, or services; or(6)(b) violation of a provision of Sections 26B-3-1102 through 26B-3-1106. See Utah Code 63A-13-102- Injunction: An order of the court prohibiting (or compelling) the performance of a specific act to prevent irreparable damage or injury.
- Inspector general: means the inspector general of the office, appointed under Section 63A-13-201. See Utah Code 63A-13-102
- Office: means the Office of Inspector General of Medicaid Services, created in Section 63A-13-201. See Utah Code 63A-13-102
- Person: means :
(24)(a) an individual;(24)(b) an association;(24)(c) an institution;(24)(d) a corporation;(24)(e) a company;(24)(f) a trust;(24)(g) a limited liability company;(24)(h) a partnership;(24)(i) a political subdivision;(24)(j) a government office, department, division, bureau, or other body of government; and(24)(k) any other organization or entity. See Utah Code 68-3-12.5- State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
- Waste: includes an activity that:
(13)(b)(i) does not constitute abuse or necessarily involve a violation of law; and(13)(b)(ii) relates primarily to mismanagement, an inappropriate action, or inadequate oversight. See Utah Code 63A-13-102(2) The office shall, within seven days after the day on which a hold described in Subsection(1) is ordered, notify the claimant that the hold has been placed.(3) The inspector general or the inspector general’s designee may not maintain a hold longer than is necessary to determine whether the claim, or payment of the claim, constitutes fraud, waste, or abuse, or is otherwise inaccurate.(4) A claimant may, at any time during which a hold is in place, appeal the hold underTitle 63G, Chapter 4, Administrative Procedures Act .(5) If a claim is approved or denied before a hearing is held underTitle 63G, Chapter 4, Administrative Procedures Act , the appeal shall be dismissed as moot.(6) The inspector general may request that the attorney general’s office seek an injunction to prevent a person from disposing of an asset that is potentially subject to recovery by the state to recover funds due to a person’s fraud or abuse.(7) The department and the division shall fully comply with a hold ordered under this section.