Section 0620-04-01-.01 - DEFINITIONS(1) "Commissioner" means the commissioner of Finance and Administration;(2) "Enrollee" shall mean any person eligible for and enrolled in the TennCare program;(3) "Fraud" means an intentional deception or misrepresentation made by a person including, but not limited to, a vendor, recipient, provider, or enrollee, with the knowledge that the deception or misrepresentation could result in some unauthorized benefit or payment to oneself or some other person. It includes any act that constitutes fraud under applicable federal or state law including, but not limited to, the Tennessee Medicaid False Claims Act, compiled under Tenn. Code Ann. §§ 71-5-181 - 71-5-186;(4) "Inspector General" means the person who directs the Office of Inspector General, pursuant to Tenn. Code Ann. § 71-5-2502;(5) "Provider" shall mean an institution, facility, agency, person, corporation, partnership, unincorporated organization, nonprofit organization, or any person or entity directly or indirectly providing benefits, goods or services to a TennCare enrollee. Provider shall also mean a provider's agent, contractor or subcontractor, such as a billing agent;(6) "TennCare" means the program administered by the Single State agency as designated by the State and CMS pursuant to Title XIX of the Social Security Act and section 1115 Research and Demonstration waiver granted to the State of Tennessee and any successor programs;(7) "Vendor" means any person, institution, agency, other entity or business concern providing services or goods authorized under title 71, chapter 5, part 1, and included, but is not limited to, any health maintenance organization, managed care organization, managed care contractor, administrative services organization, pharmacy benefit manager, prepaid limited health service organization, contractor or subcontractor;Tenn. Comp. R. & Regs. 0620-04-01-.01
Original rule filed July 26, 2006; effective November 28, 2006.Authority: T.C.A. §§ 71-5-2503 through 71-5-2505, 71-5-2507 through 71-5-2509, 71-5-2512 through 715-2515 and 71-5-181 through 71-5-186.