20-77-901. Definitions.

20-77-901. Definitions. As used in this subchapter: (1) “Arkansas Medicaid Program” means the program authorized under Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq., that provides for payments for medical goods or services on behalf of indigent families with dependent children and of aged, blind, or disabled individuals whose income and resources are insufficient to meet the cost of necessary medical services, including all transactions through the actual delivery of healthcare goods or services to a Medicaid recipient regardless of whether the healthcare goods or services are paid for directly by the Department of Human Services or indirectly through a fiscal agent, contractor, subcontractor, risk-based provider organization, managed care organization, or individual; (2)(A) “Claim” means any request or demand for money or property, regardless of whether under a contract, that: (i) Is presented to an officer, employee, agent, or fiscal agent of the Arkansas Medicaid Program; and (ii) Is made to a contractor, grantee, or other recipient if: (a) The money or property is spent or used on behalf of the Arkansas Medicaid Program or to advance the Arkansas Medicaid Program or its interest; and (b) The Arkansas Medicaid Program: (1) Provides or has provided any portion of the money or property requested or demanded; or (2) Is reimbursing the contractor, grantee, or other recipient for any portion of the money or property that is requested or demanded. (B) “Claim” includes: (i) Billing documentation; (ii) All documentation required to be created or maintained by law or rule to justify, support, or document the delivery of healthcare goods or services to a Medicaid recipient; (iii) All documentation submitted to justify or help establish a unit rate, capitated rate, or other method of determining what is to be paid for healthcare goods or services delivered to Medicaid recipients; and (iv) All transactions in payment for healthcare goods or services delivered or claimed to have been delivered to Medicaid recipients under the Arkansas Medicaid Program regardless of whether the State of Arkansas has title to the money or property or has transferred responsibility for delivering healthcare services to another legal entity; (3) “Damages” means the actual loss to the Arkansas Medicaid Program and its fiscal agents, including the total amount of all claims paid as a result of any false claim and the value of healthcare goods or services paid for but not delivered to a Medicaid recipient; (4) “Fiscal agent” means any individual, firm, corporation, professional association, partnership, organization, risk-based provider organization, managed care organization, or other legal entity that receives, processes, or pays claims for the delivery of healthcare goods and services to Medicaid recipients under the Arkansas Medicaid Program; (5)(A) “Knowing” or “knowingly” means that the person has actual knowledge of the information or acts in deliberate ignorance or reckless disregard of the truth or falsity of the information. (B) “Knowing” or “knowingly” does not require proof of a specific intent to defraud; (6) “Managed care organization” means a health insurer, Medicaid provider, or other business entity authorized by state law or through a contract with the state to receive a fixed or capitated rate or fee to manage all or a portion of the delivery of healthcare goods or services to Medicaid recipients; (7) “Material” means having a natural tendency to influence, or be capable of influencing, the payment or receipt of money or property; (8)(A) “Medicaid provider” means a person, business organization, risk-based provider organization, or managed care organization that delivers, purports to deliver, or arranges for the delivery of healthcare goods or services to a Medicaid recipient under the Arkansas Medicaid Program. (B) “Medicaid provider” includes an employee, agent, representative, contractor, or subcontractor of a person, business organization, risk-based provider organization, or managed care organization; (9) “Medicaid recipient” means any individual on whose behalf any person claimed or received any payment or payments from the Arkansas Medicaid Program or its fiscal agents, whether or not the individual was eligible for benefits under the Arkansas Medicaid Program; (10) “Obligation” means an established duty arising from: (A) An express or implied contract, grantor-grantee, or licensor-licensee relationship; (B) A fee-based or similar relationship; (C) State law or rule; (D) Federal law or regulation; or (E) Retention of any overpayment not returned within sixty (60) days from the date of discovery by the provider; (11) “Person” means any: (A) Medicaid provider of goods or services or any employee, independent contractor, or subcontractor of the Medicaid provider, whether that provider be an individual, individual medical vendor, firm, corporation, professional association, partnership, organization, risk-based provider organization, managed care organization, or other legal entity; or (B) Individual, individual medical vendor, firm, corporation, professional association, partnership, organization, risk-based provider organization, managed care organization, or other legal entity, or any employee of any individual, individual medical vendor, firm, corporation, professional association, partnership, organization, risk-based provider organization, managed care organization, or other legal entity, not a Medicaid provider under the Arkansas Medicaid Program but that provides goods or services to a Medicaid provider under the Arkansas Medicaid Program for which the Medicaid provider submits claims to the Arkansas Medicaid Program or its fiscal agents; and (12)(A) “Records” means all documents in any form that disclose the nature, extent, and level of healthcare goods and services provided to Medicaid recipients. (B) “Records” includes X-rays, magnetic resonance imaging scans, computed tomography scans, computed axial tomography scans, and other diagnostic imaging commonly used and retained as part of the medical records of a patient.