Terms Used In Montana Code > Title 53 > Chapter 6 - Health Care Services

• Abuse: means conduct by an applicant, recipient, 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 an incorrect determination that a person is eligible for medical assistance or payment by a medicaid agency of medical assistance payments to which the provider is not entitled. See Montana Code 53-6-155
• 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. See Montana Code 53-6-1401
• act: means the Montana Health and Economic Livelihood Partnership Act provided for in Title 39, chapter 12, and this part. See Montana Code 53-6-1303
• Affidavit: A written statement of facts confirmed by the oath of the party making it, before a notary or officer having authority to administer oaths.
• Affidavit: means a sworn written declaration made before an officer authorized to administer oaths or an unsworn written declaration made under penalty of perjury as provided in 1-6-105. See Montana Code 1-1-203
• Allegation: something that someone says happened.
• Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
• Applicant: means a person:

  (a)who has submitted an application for determination of medicaid eligibility to a medicaid agency on the person's own behalf or on behalf of another person; or

  (b)on whose behalf an application has been submitted. See Montana Code 53-6-155

• Arrest: Taking physical custody of a person by lawful authority.
• Assets: (1) The property comprising the estate of a deceased person, or (2) the property in a trust account.
• 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
• Benefit: means the provision of anything of pecuniary value to or on behalf of a recipient under the medicaid program. See Montana Code 53-6-155
• Certificate: means a certificate as defined in 33-22-1107. See Montana Code 53-6-802
• 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 or that states income, expense, or other information that is or may be used to determine entitlement to or the rate of payment under the medicaid program. See Montana Code 53-6-155
• 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
• Clerk of court: An officer appointed by the court to work with the chief judge in overseeing the court's administration, especially to assist in managing the flow of cases through the court and to maintain court records.
• Commissioner: means the commissioner of insurance provided for in 2-15-1903. See Montana Code 53-6-802
• Community engagement: means participation in the activities specified in 53-6-1308 as a means to improve a program participant's well-being and opportunities for self-sufficiency. See Montana Code 53-6-1303
• Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
• Decedent: A deceased person.
• Department: means the department of public health and human services provided for in 2-15-2201. See Montana Code 53-6-155
• Department: means the department of public health and human services provided for in 2-15-2201. See Montana Code 53-6-401
• Department: means the department of public health and human services. See Montana Code 53-6-702
• Department: means the department of public health and human services provided for in 2-15-2201. See Montana Code 53-6-802
• Department: means the department of public health and human services provided for in Title 2, chapter 15, part 22. See Montana Code 53-6-1001
• Department: means the department of public health and human services provided for in 2-15-2201. See Montana Code 53-6-1303
• Department: means the department of public health and human services provided for in 2-15-2201. See Montana Code 53-6-1401
• Dependent: A person dependent for support upon another.
• Discounted price: means a price set by the department by rule pursuant to 53-6-1002. See Montana Code 53-6-1001
• Document: means any application, claim, form, report, record, writing, or correspondence, whether in written, electronic, magnetic, or other form. See Montana Code 53-6-155
• Dollar-for-dollar model: means a program in which the amount of resources that is disregarded in determining medical assistance eligibility for an individual is increased by $1 for each dollar paid by an insurer to an insured under the insured's long-term care insurance policy or certificate. See Montana Code 53-6-802
• Entitlement: A Federal program or provision of law that requires payments to any person or unit of government that meets the eligibility criteria established by law. Entitlements constitute a binding obligation on the part of the Federal Government, and eligible recipients have legal recourse if the obligation is not fulfilled. Social Security and veterans' compensation and pensions are examples of entitlement programs.
• entity: means a health maintenance organization or an insurer regulated under Title 33 that:

  (i)contracts for an estimated annual value of $1 million or more of state and federal medicaid funds; or

  (ii)operates statewide or covers 20% or more of the medicaid population. See Montana Code 53-6-702

• 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
• Fair market value: The price at which an asset would change hands in a transaction between a willing, informed buyer and a willing, informed seller.
• Financial institution: means any organization in the business of moving, investing, or lending money, dealing in financial instruments, or providing financial services, including but not limited to federally chartered and state-chartered banks, savings and loan associations, and credit unions. See Montana Code 53-6-165
• Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
• 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
• form: means one of the types of local government enumerated in 7-3-102 and the type of government described in 7-3-111. See Montana Code 7-3-122
• Fraud: means any 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 or benefits to which the applicant, recipient, or provider is not entitled. See Montana Code 53-6-155
• 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
• Health maintenance organization: means a health maintenance organization as defined in 33-31-102. See Montana Code 53-6-702
• 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

• Home and community-based services: means , as provided for in section 1915 of Title XIX of the Social Security Act, 42 U. See Montana Code 53-6-401
• 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. See Montana Code 53-6-1401
• Joint tenancy: A form of property ownership in which two or more parties hold an undivided interest in the same property that was conveyed under the same instrument at the same time. A joint tenant can sell his (her) interest but not dispose of it by will. Upon the death of a joint tenant, his (her) undivided interest is distributed among the surviving joint tenants.
• Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
• Lease: A contract transferring the use of property or occupancy of land, space, structures, or equipment in consideration of a payment (e.g., rent). ^{Source: OCC}
• Legislative session: That part of a chamber's daily session in which it considers legislative business (bills, resolutions, and actions related thereto).
• Level-of-care determination: means an assessment of a person and the resulting determination establishing whether long-term care facility services to be provided to the person are appropriate to meet the health care and related circumstances and needs of the person. See Montana Code 53-6-401
• Life estate: A property interest limited in duration to the life of the individual holding the interest (life tenant).
• Long-term care facility: means a facility that is certified by the department, as provided in 53-6-106, to provide skilled or intermediate nursing care services, including intermediate nursing care services for persons with developmental disabilities or, for the purposes of implementation of medicaid-funded programs of home and community-based services, that is recognized by the U. See Montana Code 53-6-401
• Long-term care insurance: means an insurance policy or certificate that provides coverage for medically necessary services in a long-term care facility, as defined in 50-5-101, or in the insured's home. See Montana Code 53-6-802
• Long-term care preadmission screening: means , in accordance with section 1919 of Title XIX of the Social Security Act, 42 U. See Montana Code 53-6-401
• Manufacturer: means a manufacturer of prescription drugs and includes a subsidiary or affiliate of a manufacturer. See Montana Code 53-6-1001
• Medicaid: means the Montana medical assistance program established under Title 53, chapter 6. See Montana Code 53-6-155
• Medicaid: means the Montana medical assistance program established under Title 53, chapter 6. See Montana Code 53-6-1401
• Medicaid agency: means any agency or entity of state, county, or local government that administers any part of the medicaid program, whether under direct statutory authority or under contract with an authorized agency of the state or federal government. See Montana Code 53-6-155
• Member: means an individual enrolled in the Montana medicaid program pursuant to 53-6-131 or receiving medicaid-funded services pursuant to 53-6-1304. See Montana Code 53-6-1303
• Misappropriation of patient property: means exploitation, deliberate misplacement, or wrongful use or taking of a patient's property, whether temporary or permanent, without authorization by the patient or the patient's designated representative. See Montana Code 53-6-155
• Mortgage: The written agreement pledging property to a creditor as collateral for a loan.
• Mortgagee: The person to whom property is mortgaged and who has loaned the money.
• Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
• Originating site provider: means an enrolled provider who is operating a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996, 42 U. See Montana Code 53-6-155
• 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

• Oversight: Committee review of the activities of a Federal agency or program.
• participant: means an individual enrolled in the Montana Health and Economic Livelihood Partnership Act program established in Title 39, chapter 12, and this part. See Montana Code 53-6-1303
• Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
• Patient abuse: means the willful infliction of physical or mental injury of a patient or unreasonable confinement, intimidation, or punishment that results in pain, physical or mental harm, or mental anguish of a patient. See Montana Code 53-6-155
• Patient neglect: means a failure, through inattentiveness, carelessness, or other omission, to provide to a patient goods and services necessary to avoid physical harm, mental anguish, or mental illness when an omission is not caused by factors beyond the person's control or by good faith errors in judgment. See Montana Code 53-6-155
• Peace officer: has the meaning as defined in 46-1-202. See Montana Code 1-1-207
• 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. See Montana Code 53-6-1401

• Personal property: All property that is not real property.
• Personal property: means money, goods, chattels, things in action, and evidences of debt. See Montana Code 1-1-205
• Persons with disabilities or persons who are elderly: means , for purposes of establishing home and community-based services, those categories of persons who are elderly and disabled as defined in accordance with section 1915 of Title XIX of the Social Security Act, 42 U. See Montana Code 53-6-401
• Policy: means a policy as defined in 33-22-1107. See Montana Code 53-6-802
• Probate: Proving a will
• Program: means an element of the integrated health care system created by this part. See Montana Code 53-6-702
• Program: means the prescription drug plus discount program provided for in 53-6-1002. See Montana Code 53-6-1001
• Prosecute: To charge someone with a crime. A prosecutor tries a criminal case on behalf of the government.
• 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 part. See Montana Code 53-6-155
• 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
• Public law: A public bill or joint resolution that has passed both chambers and been enacted into law. Public laws have general applicability nationwide.
• Real property: Land, and all immovable fixtures erected on, growing on, or affixed to the land.
• Real property: means lands, tenements, hereditaments, and possessory title to public lands. See Montana Code 1-1-205
• Recipient: means a person:

  (a)who has been determined by a medicaid agency to be eligible for medicaid benefits, whether or not the person actually has received any benefits; or

  (b)who actually receives medicaid benefits, whether or not determined eligible. See Montana Code 53-6-155

• 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 a recipient;

  (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 53-6-155

• 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

• Recoverable medical assistance: means a payment pursuant to this part, including but not limited to a payment made for items or services provided to and insurance premiums, deductibles, and coinsurance paid on behalf of a recipient who:

  (i)during the recipient's lifetime, was an inpatient in a nursing facility, intermediate care facility for the developmentally disabled, or institution for mental disease and, with respect to that institutionalization, the department determined under 53-6-171 that the person was not reasonably expected to be discharged and return home; or

  (ii)was at least 55 years of age or younger if allowed by 42 U. See Montana Code 53-6-165

• Recovery: means legal action brought for the payment or repayment of recoverable medical assistance or amounts of money paid for other purposes. See Montana Code 53-6-165
• 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. See Montana Code 53-6-1401
• Remainder: An interest in property that takes effect in the future at a specified time or after the occurrence of some event, such as the death of a life tenant.
• Right of survivorship: The ownership rights that result in the acquisition of title to property by reason of having survived other co-owners.
• Secondary discounted price: means the discounted price less any further discounts funded by manufacturer rebates for medication purchased by participants in the program. See Montana Code 53-6-1001
• Significant error rate: means previous billing errors greater than 5% of the total lines reviewed. See Montana Code 53-6-1401
• Statute: A law passed by a legislature.
• Statute of limitations: A law that sets the time within which parties must take action to enforce their rights.
• Telehealth: means the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision, and information across distance, including but not limited to the use of secure portal messaging, secure instant messaging, audiovisual communications, and audio-only communications. See Montana Code 53-6-155
• Tenancy in common: A type of property ownership in which two or more individuals have an undivided interest in property. At the death of one tenant in common, his (her) fractional percentage of ownership in the property passes to the decedent
• Trial: A hearing that takes place when the defendant pleads "not guilty" and witnesses are required to come to court to give evidence.
• Trustee: A person or institution holding and administering property in trust.
• Writ: A formal written command, issued from the court, requiring the performance of a specific act.
• Writ: means an order in writing issued in the name of the state or of a court or judicial officer. See Montana Code 1-1-202
• Writing: includes printing. See Montana Code 1-1-203