Medicaid Fraud Control Sample Clauses

Medicaid Fraud Control. Unit (MFCU) means the statutorily authorized criminal investigation unit in the Utah Attorney General’s Office charged with investigating and prosecuting Medicaid Fraud. Medicaid Information Bulletin (MIB) means the official, periodic publication of the Division of Integrated Healthcare to update the Utah Medicaid Provider Manual or issue information to Medicaid Providers. Medical Loss Ratio (MLR) means the calculation the Contractor is required to quantify and report to the Department pursuant to 42 CFR § 438.8. Medically Necessary or Medical Necessity means medically necessary service as defined by Utah Administrative Code R414-1-2.
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Medicaid Fraud Control. Unit (MFCU) means the statutorily authorized criminal investigation unit in the Utah Attorney General’s Office charged with investigating and prosecuting Medicaid Fraud. Medicaid Information Bulletin (MIB) means the official, periodic publication of the Division of Medicaid and Health Financing to update the Utah Medicaid Provider Manual or issue information to Medicaid providers. Medical Loss Ratio (MLR) means a measure of the percentage of premium dollars that a health plans spends on medical claims and quality improvements, versus administrative costs. MLR is described in Article 12.5. Medically Necessary or Medical Necessity means needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine. Member Services means a method of assisting Enrollees in understanding Contractor policies and procedures, facilitating referrals to participating specialists, and assisting in the resolution of problems and member complaints. The purpose of Member Services is to improve access to services and promote Enrollee satisfaction. National Committee for Quality Assurance (NCQA) means a private, non-profit organization dedicated to improving health care quality by evaluating and reporting on the quality of managed care and other health care organizations in the United States. NCQA developed HEDIS and maintains and updates a database of HEDIS results.
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Medicaid Fraud Control. Unit (MFCU) means the statutorily authorized criminal investigation unit charged with investigating and prosecuting the Medicaid and CHIP fraud in the Utah Attorney General’s Office. Medically Necessary or Medical Necessity means any medical service that is (1) reasonably calculated to prevent, diagnose, or cure conditions in the Enrollee that endanger life, cause suffering or pain, cause deformity or malfunction, or threaten to cause a handicap; and (2) there is no equally effective course of treatment available or suitable for the Enrollee requesting the service which is more conservative or substantially less costly. To be considered Medically Necessary, the medical services shall be of a quality that meets professionally recognized standards of dental care, and shall be substantiated by records including evidence of such medical necessity and quality. Those records will be made available to the Department upon request.
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Medicaid Fraud Control. Unit (MFCU) means the statutorily authorized criminal investigation unit in the Utah Attorney General’s Office charged with investigating and prosecuting Medicaid Fraud. Medicaid Information Bulletins (MIB) means an official, periodic publication of the Division of Medicaid and Health Financing to update the Utah Medicaid Provider Manual or issue information to Medicaid providers. Medical Institution means a facility designed primarily to provide medical care. Medical Institutions include, but are not limited to: Hospitals, SNFs, ICFs, The Utah State Developmental Center, and IMDs. Medical Loss Ratio (MLR) means a measure of the percentage of premium dollars that a health plan spends on medical claims and quality improvements, versus administrative costs. Medically Necessary or Medical Necessity means Medically Necessary Service as defined by Utah Administrative Code R414-1-2.
Sample 1Sample 2
Medicaid Fraud Control. Unit (MFCU) means the statutorily authorized criminal investigation unit in the Utah Attorney General’s Office charged with investigating and prosecuting Medicaid Fraud. Medicaid Information Bulletin (MIB) means the official, periodic publication of the Division of Integrated Healthcare to update the Utah Medicaid Provider Manual or issue information to Medicaid Providers. Medical Institution means a facility designed primarily to provide medical care. Medical Institutions include, but are not limited to: Hospitals, SNFs, ICFs, The Utah State Developmental Center, and IMDs. Medical Loss Ratio (MLR) means the calculation the Contractor is required to quantify and report to the Department pursuant to 42 CFR § 438.8. Medically Necessary or Medical Necessity means medically necessary service as defined by Utah Administrative Code R414-1-2.
Sample 1Sample 2
Medicaid Fraud Control. Unit (MFCU) means the statutorily authorized criminal investigation unit charged with investigating and prosecuting the Medicaid fraud in the Utah Attorney General’s Office. Medically Necessaryor Medical Necessity means Medically Necessary Service as defined by Utah Administrative Code R414-1-2(18).
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Medicaid Fraud Control. Unit (MFCU). As required by federal regulations, the Health Care Authority, the Department of Social and Health Services, and any contractors or subcontractors, shall promptly comply with all MFCU requests for records or information. Records and information includes, but is not limited to, records on micro-fiche, film, scanned or imaged documents, narratives, computer data, hard copy files, verbal information, or any other information the MFCU determines may be useful in carrying out its responsibilities.
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Related to Medicaid Fraud Control

  • Medicaid If and when the Resident’s assets/funds have fallen below the Medicaid eligibility levels, and the Resident otherwise satisfies the Medicaid eligibility requirements and is not entitled to any other third party coverage, the Resident may be eligible for Medicaid (often referred to as the “payor of last resort”). THE RESIDENT, RESIDENT REPRESENTATIVE AND SPONSOR AGREE TO NOTIFY THE FACILITY AT LEAST THREE (3) MONTHS PRIOR TO THE EXHAUSTION OF THE RESIDENT’S FUNDS (APPROXIMATELY $50,000) AND/OR INSURANCE COVERAGE TO CONFIRM THAT A MEDICAID APPLICATION HAS OR WILL BE SUBMITTED TIMELY AND ENSURE THAT ALL ELIGIBILITY REQUIREMENTS HAVE BEEN MET. THE RESIDENT, RESIDENT REPRESENTATIVE AND/OR SPONSOR AGREE TO PREPARE AND FILE AN APPLICATION FOR MEDICAID BENEFITS PRIOR TO THE EXHAUSTION OF THE RESIDENT’S RESOURCES. Services reimbursed under Medicaid are outlined in Attachment “A” to this Agreement. Once a Medicaid application has been submitted on the Resident’s behalf, the Resident, Sponsor, and Resident Representative agree to pay, to the extent they have access to the Resident’s funds, to the Facility the Resident’s monthly income, which will be owed to the Facility under the Resident’s Medicaid budget. Medicaid recipients are required to pay their Net Available Monthly Income (“NAMI”) to the Facility on a monthly basis as a co-payment obligation as part of the Medicaid rate. A Resident’s NAMI equals his or her income (e.g., Social Security, pension, etc.), less allowed deductions. The Facility has no control over the determination of NAMI amounts, and it is the obligation of the Resident, Resident Representative and/or Sponsor to appeal any disputed NAMI calculation with the appropriate government agency. Once Medicaid eligibility is established, the Resident, Resident Representative and/or Sponsor agree to pay NAMI to the Facility or to arrange to have the income redirected by direct deposit to the Facility and to ensure timely Medicaid recertification. The Resident, Sponsor and Resident Representative agree to provide to the Facility copies of any notices (such as requests for information, budget letters, recertification, denials, etc.) they receive from the Department of Social Services related to the Resident’s Medicaid coverage. Until Medicaid is approved, the Facility may bill the Resident’s account as private pay and the Resident will be responsible for the Facility’s private pay rate. If Medicaid denies coverage, the Resident or the Resident’s authorized representative can appeal such denial; however, payment for any uncovered services will be owed to the Facility at the private pay rate pending the appeal determination. If Medicaid eligibility is established and retroactively covers any period for which private payment has been made, the Facility agrees to refund or credit any amount in excess of the NAMI owed during the covered period.

  • Medicaid Enrollment Treatment Grantees shall enroll as a provider with Texas Medicaid and Healthcare Partnership (TMHP) and all Medicaid Managed Care organizations in Grantee’s service region within the first quarter of this procurement term and maintain through the procurement term.

  • Medicaid Program Contractors Inspection of Records: Any contracts accessing payments for services through the Global Commitment to Health Waiver and Vermont Medicaid program must fulfill state and federal legal requirements to enable the Agency of Human Services (AHS), the United States Department of Health and Human Services (DHHS) and the Government Accounting Office (GAO) to: Evaluate through inspection or other means the quality, appropriateness, and timeliness of services performed; and Inspect and audit any financial records of such Contractor or subcontractor.

  • Medicaid Program Parties (applicable to any Party providing services and supports paid for under Vermont’s Medicaid program and Vermont’s Global Commitment to Health Waiver):

  • Medicare If the Resident meets the eligibility requirements for skilled nursing facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines thereto. If the Resident continues to be eligible, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are fully paid by Medicare and the next 80 days (days 21 through 100) of the covered services are paid in part by Medicare and subject to a daily coinsurance amount for which the Resident is responsible. A Resident with Medicare Part B and/or Part D coverage, who subsequently exhausts his/her Part A coverage or no longer needs a skilled level of care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or Part D services when Part A coverage ends. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident would be responsible for the cost of his/her stay, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facility, the Resident, Resident Representative, and/or Sponsor hereby agree to pay to the Facility any outstanding amounts for unpaid services not covered by other third party payers, subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. Except for specifically excluded services, most nursing home services are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third party insurers and managed care organizations (MCOs). Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from the Facility. MEDICARE PART A, MANAGED CARE, AND THIRD-PARTY INSURANCE

  • Child Care Leave (a) An employee who is a natural or adoptive parent shall be granted upon request in writing child care leave without pay for a period of up to thirty-five (35) weeks. The leave may be shared by the parents or taken wholly by one (1) parent.

  • Fair Employment Practices and Americans with Disabilities Act Party agrees to comply with the requirement of Title 21V.S.A. Chapter 5, Subchapter 6, relating to fair employment practices, to the full extent applicable. Party shall also ensure, to the full extent required by the Americans with Disabilities Act of 1990, as amended, that qualified individuals with disabilities receive equitable access to the services, programs, and activities provided by the Party under this Agreement. Party further agrees to include this provision in all subcontracts.

  • Xxxxx Care Leave Leave may be granted to any employee, upon request, to care for or to arrange for care for parents of the employee or the employee's spouse.

  • Primary Care Clinic Employees and each of their covered dependents must individually elect a primary care clinic within the network of providers offered by the plan administrator chosen by the employee. Employees and their dependents may elect to change clinics within their clinic’s Benefit Level as often as the plan administrator permits and as outlined above.

  • Family Care and Medical Leave An unpaid Family Care and Medical Leave shall be granted, to the extent of and subject to the restrictions as set forth below, to an employee who has been employed for at least twelve (12) months and who has served for one hundred thirty days (130) workdays during the twelve (12) months immediately preceding the effective date of the leave. For purposes of this section, furlough days and days worked during off-basis time shall count as "workdays". Family Care and Medical Leave absences of twenty (20) consecutive working days or less can be granted by the immediate administrator or designee. Leaves of twenty (20) or more consecutive working days can be granted only by submission of a formal leave application to the Classified Personnel Assignments Branch.

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