§ 40-8.2-2 - Definitions. - Rhode Island Statutes

SECTION 40-8.2-2

   § 40-8.2-2  Definitions. – Whenever used in this chapter:

   (1) "Benefit" means pecuniary benefit as defined herein.

   (2) "Claim" means any request for payment, electronic orotherwise, and shall also include any data commonly known as encounter data,which is used or is to be used for the development of a capitation fee payableto a provider of managed health care goods, merchandise or services.

   (3) "Department" means the Rhode Island department of humanservices.

   (4) "Fee schedule" means a list of goods or services to berecognized as properly compensable under the Rhode Island Medicaid program andapplicable rates of reimbursement.

   (5) "Kickback" means a return in any form by any individualof a part of an expenditure made by a provider:

   (i) To the same provider;

   (ii) To an entity controlled by the provider; or

   (iii) To an entity, which the provider intends to benefitwhenever the expenditure is reimbursed, or reimbursable, or claimed by aprovider as being reimbursable by the Rhode Island Medicaid program and whenthe sum or value returned is not credited to the benefit of the Rhode IslandMedicaid program.

   (6) "Medicaid fraud control unit" means a duly certifiedMedicaid fraud control unit under federal regulation authorized to performthose functions as described by § 1903(q) of the Social Security Act, 42U.S.C. § 1396b(q).

   (7) "Medically unnecessary services or merchandise" meansservices or merchandise provided to recipients intentionally without anyexpectation that the services or merchandise will alleviate or aid therecipient's medical condition.

   (8) "Pecuniary benefit" means benefit in the form of money,property, commercial interests, or anything else the primary significance ofwhich is economic gain.

   (9) "Person" means any person or individual, natural orotherwise and includes those person(s) or entities defined by the term"provider".

   (10) "Provider" means any individual, individual medicalvendor, firm, corporation, professional association, partnership, organization,or other legal entity that provides goods or services under the Rhode IslandMedicaid program or the employee of any person or entity who, on his or her ownbehalf or on the behalf of his or her employer, knowingly performs any act oris knowingly responsible for an omission prohibited by this chapter.

   (11) "Recipient" means any person receiving medicalassistance under the Rhode Island Medicaid program.

   (12) "Records" means all documents developed by a providerand related to the provision of services reimbursed or claimed as reimbursableby the Rhode Island Medicaid program.

   (13) "Rhode Island Medicaid program" means a stateadministered, medical assistance program which is funded by the state andfederal governments under Title XIX, Social Security Act, 42 U.S.C. § 1396et seq.