La. Admin. Code tit. 50 § I-1519
Current through Register Vol. 50, No. 11, November 20, 2024
Section I-1519 - DefinitionsA. As used in this Subpart the following terms shall have the following meanings:1.Agent-a person who is employed by or has a contractual relationship with a provider or who acts on behalf of the provider.2.Beneficiary-an individual who is enrolled to receive health care through the Medical Assistance Program.3.Claim-any request or demand, including any and all documents or information required by federal or state law or by rule made against Medical Assistance Program funds for payment. A claim may be based on costs or projected costs and includes any entry or omission in a cost report or similar document, book of account, or any other document which supports, or attempts to support, the claim. Each claim may be treated as a separate claim, or several claims may be combined to form one claim.4.Department-the Louisiana Department of Health (LDH).5.Disclosed Individuals-persons required to be disclosed to the department, as the Medicaid agency, by the provider, such as, but not limited to:a.Agents or Managing Employees-Pursuant to 42 C.F.R. § 455.106(a), a provider must disclose to the Medicaid agency the identity of each person who is an agent or managing employee of the provider and has been convicted of certain crimes. An agent or managing employee is any individual who exercises operational or managerial control, conducts day-to-day operations of the provider agency, or any person with authority to obligate or act on behalf of the disclosing entity, such as, but not limited to, a general manager, business manager, administrator, board member, chief operating officer, trustee, or partner.b.Persons with Ownership or Control Interest- Pursuant to 42 C.F.R. § 455.104(b), a provider must disclose the identity of all persons that have an ownership or control interest (either separately or in combination) of 5 percent or more in the provider.6.Division of Administrative Law-the Louisiana Division of Administrative Law, which operates as Louisiana's centralized administrative hearings panel for disputes between government agencies and regulated individuals and entities.7.Federal Regulations-the provisions contained in the Code of Federal Regulations (C.F.R.) or the Federal Register (FR).8.General Terms-Definitions contained in applicable federal laws and regulations shall also apply to this Subpart and all department regulations. In the case of a conflict between federal definitions and departmental definitions, the department's definition shall apply unless the federal definition, as a matter of law, supersedes a departmental definition. Definitions contained in applicable state laws shall also apply to this and all departmental definitions. In the case of a conflict between a state statutory definition and a departmental definition, the departmental definition shall apply unless the state statutory definition, as a matter of state law, supersedes the departmental definition.9.Informal Hearing-an informal conference between the provider, or other persons and the section chief of Medicaid Program Operations and Compliance or his/her designee and the Medicaid director or his/her designee.10.Medical Assistance Program or Medicaid-the Medical Assistance Program (Title XIX) of the Social Security Act administered by the Department of Health, commonly referred to as Medicaid, the Medicaid Program, or Bureau of Health Services Financing (BHSF).11.Notice of Action-a written notification of an action taken or to be taken by the department or BHSF, including a notice of termination of enrollment in the Medicaid Program or a notice of denial of enrollment in the Medicaid Program.12.Person-any natural person, company, corporation, partnership, firm, association, group, or other legal entity or as provided by law.13.Provider-a health care provider as defined in R.S. 46:437.3(A)(9).14.Provider Agreement-the document(s), including electronic documents, signed by or on behalf of the provider in accordance with R.S. 46:437.11-437.14, which enrolls the provider in the Medical Assistance Program and grants to the provider a provider number and the privilege to participate in the Medical Assistance Program. This definition shall not be construed to conflict with the definition of provider agreement included in R.S. 437.3(A)(21).15.Provider Enrollment-the process through which a person or provider becomes enrolled in the Medical Assistance Program through the department for the purpose of providing goods, services, or supplies to one or more Medicaid beneficiaries.16.Provider Number-a provider's billing or claim reimbursement number issued by the department through BHSF under the Medical Assistance Program.17.Rule or Regulation-any rule or regulation promulgated by the department in accordance with the Administrative Procedure Act and any federal rule or regulation promulgated by the federal government in accordance with federal law.18.Secretary-the Secretary of the Department of Health.19.Termination-the termination or revocation of the provider agreement with the department to participate in the Medical Assistance Program. In a termination action, the state Medicaid agency has taken an action to revoke the provider's billing privileges, and the provider has exhausted all applicable appeal rights or the timeline for appeal has expired. The requirement for termination applies in cases where providers, suppliers, or eligible professionals were terminated or had their billing privileges revoked for cause which may include, but is not limited to: 20.Trade Areas-Arkansas, Mississippi, and Texas counties directly touching Louisiana parish borders. Trade areas are treated with the same criteria as in-state providers.La. Admin. Code tit. 50, § I-1519
Promulgated by the Department of Health, Bureau of Health Services Financing, LR 50981 (7/1/2024).AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.