Medicaid Fraud definition

Medicaid Fraud means the providing of false information to claim reimbursement for Medicaid funded services. Medicaid Fraud includes, but is not limited to, the following activities: billing for services not actually performed; billing for more expensive services than actually rendered; billing for several services that should be combined into one billing; and billing twice for the same service.
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Medicaid Fraud. The intentional deception or misinterpretation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or another person. 42 CFR 455.2 Per Eligible Per Month (PEPM): A fixed monthly rate per Medicaid eligible person payable to the PIHP by the MDCH for provision of Medicaid services defined within this contract. Persons with Limited English Proficiency (LEP): Individuals who cannot speak, write, read or understand the English language at a level that permits them to interact effectively with health care providers and social service agencies. Michigan Medicaid Provider Manual: Mental Health-Substance Abuse section: The Michigan Department of Community Health periodically issues notices of proposed policy for the Medicaid program. Once a policy is final, MDCH issues policy bulletins that explain the new policy and give its effective date. These documents represent official Medicaid policy and are included in the Michigan Medicaid Provider Manual: Mental Health Substance Abuse section. Post-stabilization Services: Covered specialty services specified in Section 2.0 that are related to an emergency medical condition and that are provided after a beneficiary is stabilized in order to maintain the stabilized condition, or, under the circumstances described in 42 CFR 438.114(e) to improve or resolve the beneficiary's condition. Practice Guideline: MDCH-developed guidelines for PIHPs and CMHSPs for specific service, support or systems models of practice that are derived from empirical research and sound theoretical construction and are applied to the implementation of public policy. Prepaid Inpatient Health Plan (PIHP): An organization that manages Medicaid specialty services under the state's approved Concurrent 1915(b)/1915(c) Waiver Program, on a prepaid, shared-risk basis, consistent with the requirements of 42 CFR part 401 et al June 14, 2002, regarding Medicaid managed care. (In Medicaid regulations, Prepaid Health Plans (PHPs) that are responsible for inpatient services as part of a benefit package are now referred to as "PIHP" (Prepaid Inpatient Health Plan).
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Medicaid Fraud means: (1)—(5) (text unchanged)
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Examples of Medicaid Fraud in a sentence

  • The PH-MCO’s Fraud, Waste and Abuse policies and procedures must provide and certify that the PH-MCO’s Fraud, Waste and Abuse unit as well as the entire Department, the Pennsylvania Office of Attorney General Medicaid Fraud Control Section and their third-party designees, including CMS Contractors have timely access to records of Network Providers, Subcontractors, and the PH- MCOs, as outlined in this Agreement.

  • A standardized referral process is outlined in Exhibit KK of this Agreement, Reporting Suspected Fraud, Waste and Abuse to the Department and to the Pennsylvania Office of Attorney General Medicaid Fraud Control Section.

  • The PH-MCO must establish a policy for prompt referral of suspected Fraud, Xxxxx and Abuse to the Department and also referral of suspected Fraud to the Pennsylvania Office of Attorney General, Medicaid Fraud Control Section as required in 42 C.F.R. §438.608(a)(7).

  • Medicaid Fraud Control Unit (MFCU) – Consistent with OAC rule 5160-26-01, the unit of the Ohio Attorney General's Office responsible for the investigation and prosecution of fraud and related offenses within Medicaid.

  • This thirty (30) Days notice does not apply to records requested by the state or federal government including the Pennsylvania Office of Attorney General’s Medicaid Fraud Control Unit, for purposes of fiscal audits or Fraud and/or Abuse investigations.

Related to Medicaid Fraud

  • Medicaid means that government-sponsored entitlement program under Title XIX, P.L. 89-97 of the Social Security Act, which provides federal grants to states for medical assistance based on specific eligibility criteria, as set forth on Section 1396, et seq. of Title 42 of the United States Code.

  • Medicare means the “Health Insurance for the Aged Act,” Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended.

  • Medicare Advantage The Medicare managed care options that are authorized under Title XVIII as specified at Part C and 42 C.F.R. § 422.

  • Centers for Medicare and Medicaid Services or “CMS” means the federal office under the Secretary of the United States Department of Health and Human Services, responsible for the Medicare and Medicaid programs.

  • Medicare cost report means CMS-2552-10, the cost report for electronic filing of

  • Child care facility or “facility” means a child care center, a preschool, or a registered child development home.

  • Health care facility or "facility" means hospices licensed

  • Health care worker means a person other than a health care professional who provides medical, dental, or other health-related care or treatment under the direction of a health care professional with the authority to direct that individual's activities, including medical technicians, medical assistants, dental assistants, orderlies, aides, and individuals acting in similar capacities.

  • Medicare Advantage plan means a plan of coverage for health benefits under Medicare Part C as defined in 42 U.S.C. 1395w-28(b)(1), and includes:

  • Managed care plan means a health benefit plan that either requires a covered person to use, or

  • HIPAA means the Health Insurance Portability and Accountability Act of 1996.