S.C. Code Regs. § § 126-400

Current through Register Vol. 48, No. 9, September 27, 2024

Section 126-400 - Definitions

A. Provider - means an individual, firm, corporation, association or institution which is providing, or has been approved to provide, medical assistance to a beneficiary pursuant to the State Medical Assistance Plan and in accord with Title XIX of the Social Security Act of 1932, as amended.

B. Person - any natural person, company, firm, association, partnership, corporation or other legal entity.

C. Practitioner - means a physician or other health care professional licensed under State law to practice his or her profession.

D. Educational Intervention - means a visit to a provider by a staff member to explain Medicaid Program policies and procedures. This includes instructions on correct billing procedures. Educational intervention may also take the form of a telephone call or letter to a provider calling his or her attention to a particular problem in Program administration or billing practices.

E. Abuse - provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid Program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.

F. Fraud - an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law. [ 42 CFR § 455.2] .

G. Conviction or convicted - means a judgment or conviction after trial, or the entry of a plea of guilty or a plea of no contest (nolo contendere) in a federal, state or local court, regardless of whether an appeal from that judgment is pending.

H. Exclusion - means that a health care provider, either an individual practitioner or facility, organization, institution, business, or other type of entity, cannot receive Medicaid payment for any health care services rendered. [ 42 CFR § 455.2] .

I. Suspension of Payment - means that upon determination by the Department that there is a credible allegation of fraud against a specified provider for which an investigation is pending under the Medicaid program, all payments pending at the time of determination and all payments for items or services furnished by the specified provider will be retained by the Department until resolution of the investigation, unless the Department determines that good cause to not suspend or to only suspend in part exists, as set forth in 42 CFR § 455.23(e) and § 455.23(f) respectively. [§ 455.23].

J. Termination - occurs when the Medicare program, a State Medicaid program, or Children's Health Insurance Program (CHIP) has taken an action to revoke a provider's billing privileges, a provider has exhausted all applicable appeal rights or the timeline for appeal has expired, and there is no expectation on the part of a provider or supplier or the Medicare program, State Medicaid program, or CHIP that the revocation is temporary. The requirement for termination based upon a termination in another program applies in cases where providers, suppliers, or eligible professionals were terminated or had their billing privileges revoked for cause which may include reasons based on fraud, integrity, or quality. [Section 6501 of the Affordable Care Act amended section 1902(a)(39) of the Social Security Act (the Act) and requires State Medicaid agencies to terminate the participation of any individual or entity if such individual or entity is terminated under Medicare or under the Medicaid program or CHIP of any other state].

K. Suspension - means that items or services furnished by a specified provider who has been convicted of a program-related offense in a Federal, State, or local court will not be reimbursed under Medicaid. [ 42 CFR § 455.2] .

S.C. Code Regs. § 126-400

Replaced and amended by State Register Volume 42, Issue No. 05, eff. 5/25/2018.