Terms Used In Montana Code 53-6-1403

• 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. See Montana Code 53-6-1401
• Automated review: means a claim review that is made at the system level without a human being reviewing the medical record. See Montana Code 53-6-1401
• 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. See Montana Code 53-6-1401
• Department: means the department of public health and human services provided for in 2-15-2201. See Montana Code 53-6-1401
• Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
• 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. See Montana Code 53-6-1401
• 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. See Montana Code 53-6-1401
• 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. See Montana Code 53-6-1401

• 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. See Montana Code 53-6-1401
• 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. See Montana Code 53-6-1401

• 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. See Montana Code 53-6-1401