1. A. In addition to the definitions provided for in R.S. 46:437.3, and unless otherwise provided, the following terms shall mean:

   1. Affiliate—any person who has a direct or indirect relationship or association with a provider. A person is a presumed affiliate if the person:

      1. a. directly or indirectly influences or controls a provider or has the power to do so;
      2. b. has a direct or indirect ownership interest in a provider; or
      3. c. shares in the proceeds or has the right to share in the proceeds of a provider.
   2. Bureau of Health Services Financing (BHSF)—the division within the Department of Health responsible for administering the Louisiana Medicaid program.
   3. Contractor—any person with whom the provider has an agreement to perform a service for the provider. A contractor is presumed to be an agent of the provider.
   4. Conviction—shall have the same meaning as provided in 42 U.S.C. 1320a-7(i).
   5. Corrective Action Plan—a mutual, written agreement between the department and provider to remedy a provider’s aberrant or prohibited practices.
   6. Credible Allegation of Fraud—has the same meaning as provided in 42 CFR §405.370.
   7. Department—the Department of Health inclusive of the BHSF director and the program integrity unit section chief.
   8. Discover—the date a reasonably prudent person should have obtained knowledge or become aware of the facts in question.
   9. Division of Administrative Law (DAL)—the division of government referenced in R.S. 49:991 et seq.
   10. Final Sanction—a sanction for which the time to exercise appeal rights has expired; or, if appealed, upon the imposition of a final order in the matter.
   11. Health Oversight Agency—shall have the same meaning as provided in 45 CFR §164.501.
   12. Indirect Ownership—an ownership interest, in whole or in part, through some other entity.
   13. Managed Care Provider—any provider participating in the Medicaid program through enrollment with one or more of the State’s Managed Care Organizations. For the purposes of this Chapter, the terms provider, provider-in-fact, agent, billing agent, and contractor also applies to the managed care providers.
   14. Medicaid—any medical assistance program instituted under Title XIX, section 1900 et seq. of the Social Security Act.
   15. Medicaid Fraud Control Unit (MFCU)—the entity of state government established pursuant to 42 U.S.C 1396b(q).
   16. Notice of Action—a written notification of an action taken or to be taken by the department.
   17. Overpayment—an amount a provider received in excess of amounts properly payable for the services provided.
   18. Per Member per Month (PMPM)—the payment made to a Medicaid Managed Care Organization (MCO) or Managed Care Entity (MCE) for a Medicaid recipient enrolled with a MCO or MCE.
   19. Person—any natural person or juridical entity. This includes any company, corporation, partnership, firm, association, group, or other legal entity provided for by law.
   20. Program—any program authorized under the Medicaid Program.
   21. Program Integrity Unit (PIU)—the PIU within the department, its predecessor and successor.
   22. Provider—for the purposes of this Chapter, when the term “Provider” is used it is inclusive of provider, provider-in-fact, a provider’s agent(s), contractors and affiliates, managed care providers, or other persons potentially liable under this chapter or the Medical Assistance Programs Integrity Law, R.S. 46:437.1 et seq.
   23. Publicly Funded Healthcare Program—any healthcare program funded in whole or in part with federal or state government funds.
   24. Service—when the term “service” is used, it includes all goods, services, or supplies purportedly provided to a recipient.
   25. Statistically Valid Random Sample (SVRS)—a clearly defined universe of claims where each sampling unit has a known, non-zero probability of selection.
   26. Sub—regulatory Guidance—any policy, procedure, or rules LDH issues and the provider is required to comply with pursuant to his or her Medicaid enrollment or participation agreement.
   27. Violation—any conduct, practice, or activity not in accordance with the requirements established by law, regulation, or sub-regulatory guidance, including the provisions of this Chapter.

Authority Note

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and 46:437.1-46:440.3.

Historical Note

HISTORICAL NOTE: Promulgated by the Department of Health, Bureau of Health Services Financing, LR 52:690 (May 2026).