5-55-102. Definitions.

5-55-102. 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) “Claim” means any written or electronically submitted request or demand for reimbursement or payment made by any Medicaid provider to the Arkansas Medicaid Program, a managed care organization, or any fiscal agent of the Arkansas Medicaid Program or a managed care organization for each good or service purported to have been provided to any Medicaid recipient and all documentation required to be created or maintained by law or rule to justify, support, approve, or document the delivery of healthcare goods or services to a Medicaid recipient as a condition of participation in the Arkansas Medicaid Program as mandated by the Arkansas Medicaid Program provider agreement, rules, or managed care contract; (3) “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 or services to Medicaid recipients under the Arkansas Medicaid Program; (4)(A) “Illegal Medicaid participation” means participation in the Arkansas Medicaid Program when the individual or organization is suspended from the Arkansas Medicaid Program or on a state or federal excluded Medicaid provider list. (B) “Illegal Medicaid participation” includes without limitation when a suspended or excluded individual or organization: (i) Is employed or contracting with a Medicaid provider or managed care organization or otherwise associated with a Medicaid provider or managed care organization for the purpose of providing or supervising the provision of goods and services to Medicaid recipients; (ii) Plays any role in the management of a Medicaid provider directly as a manager or management company or indirectly as a consultant or advisor; or (iii) Receives payment for administrative and management services directly or indirectly related to patient care such as processing Medicaid claims for payment, attending to services that assist or support Medicaid recipients, or acting as a Medicaid consultant or advisor; (5) “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; (6)(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; (7) “Medicaid recipient” means any individual in whose behalf any person claimed or received any payment from the Arkansas Medicaid Program or its fiscal agents, whether or not the individual was eligible for benefits under the Arkansas Medicaid Program; (8) “Person” means any: (A) Medicaid provider of goods or services under the Arkansas Medicaid Program or any employee of the Medicaid provider, independent contractor of the Medicaid provider, contractor of the Medicaid provider, or subcontractor of the Medicaid provider, whether the Medicaid 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 (9)(A) “Records” means all documents that disclose the nature, extent, and level of healthcare goods and services provided to Medicaid recipients. (B) “Records” include 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.