9499

9499.1

For the purposes of this chapter, the following terms shall have the meanings ascribed:

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

Disclosing Entity - A prospective or enrolled Medicaid provider (other than an individual practitioner or group of practitioners), or a fiscal agent.

Fiscal Agent - A contractor that processes or pays vendor claims on behalf of the Medicaid agency.

Federal Health Care Program - Shall have the meaning ascribed in 42 USC § 1320a-7b(f).

FQHC Look-Alike – Community-based health care providers that meet the requirements of the Health Resources and Services Administration Health Center Program, established in accordance with Section 330 of the Public Health Service Act, but do not receive Health Center Program funding.

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 herself or some other person, including any act that constitutes fraud under applicable federal or District law.

Hospital-Affiliated Physician Group – An entity or group of licensed physicians operating under the terms of a contract or other business arrangement with a hospital for the purposes of managing a health care practice or providing medical services to patients.

In-District Provider - A prospective or enrolled Medicaid provider located inside of the District of Columbia Consolidated Metropolitan Statistical Area, as defined by the United States Census Bureau.

Indirect Ownership Interest - An ownership interest in an entity that has any ownership interest, direct or indirect, in the disclosing entity.

Medicaid Provider – Any District Medicaid-enrolled health care provider, including individual practitioners, institutional providers, and suppliers of

medical equipment or goods related to care.

Medicaid Provider Application - The general or provider-specific application developed by DHCF and required to initiate participation as a District Medicaid provider.

Out-of-District Provider – A prospective or enrolled Medicaid provider located outside of the District of Columbia Consolidated Metropolitan Statistical Area, as defined by the United States Census Bureau.

Ownership Interest - The possession of equity in the capital, stock or profits of a disclosing entity, including a direct or indirect ownership interest.

Provider – A prospective or enrolled Medicaid provider, including any individual practitioner, institutional provider, suppliers of medical equipment or goods, corporate entity, or principals and directors of such corporate entity.

Provider Agreement - Official enrollment document establishing roles, responsibilities, and rights of a District Medicaid provider.

Qualified Medicare Beneficiary - An individual entitled to Medicare Part A, with or without payment of premiums, whose entitlement is not solely based on eligibility to enroll under Section 1818A of the Social Security Act and who meets certain financial requirements.

SOURCE: Final Rulemaking published at 60 DCR 10041 (July 12, 2013); as amended by Final Rulemaking published at 68 DCR 4255 (April 23, 2021).