Terms Used In Montana Code 53-6-1405

• Allegation: something that someone says happened.
• 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.
• 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
• 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
• Fraud: Intentional deception resulting in injury to another.
• 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. 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
• 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. See Montana Code 53-6-1401

• Writing: includes printing. See Montana Code 1-1-203