Title 40
Human Services

Chapter 8.2
Medical Assistance Fraud

§ 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 or otherwise, and shall also include any data commonly known as encounter data, that is used, or is to be used, for the development of a capitation fee payable to a provider of managed healthcare goods, merchandise, or services.

(3) “Executive office” means the executive office of health and human services, the agency designated by state law and the Medicaid state plan as the Medicaid single state agency.

(4) “Fee schedule” means a list of goods or services to be recognized as properly compensable under the Rhode Island Medicaid program and applicable rates of reimbursement.

(5) “Kickback” means a return in any form by any individual of 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 that the provider intends to benefit whenever the expenditure is reimbursed, or reimbursable, or claimed by a provider as being reimbursable by the Rhode Island Medicaid program and when the sum or value returned is not credited to the benefit of the Rhode Island Medicaid program.

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

(7) “Medically unnecessary services or merchandise” means services or merchandise provided to recipients intentionally without any expectation that the services or merchandise will alleviate or aid the recipient’s medical condition.

(8) “Office of program integrity” or “OPI” means the division within the executive office of health and human services, authorized pursuant to § 42-7.2-18, to coordinate state and local agencies, law enforcement entities, and investigative units in order to increase the effectiveness of programs and initiatives dealing with the prevention, detection, and prosecution of Medicaid and public assistance fraud; to develop cooperative strategies to investigate and eliminate Medicaid and public assistance fraud and to recover state and federal funds; and to represent the executive office and act on the secretary’s behalf in any matters related to the prevention, detection, and prosecution of Medicaid fraud under this chapter.

(9) “Pecuniary benefit” means benefit in the form of money, property, commercial interests, or anything else the primary significance of which is economic gain.

(10) “Person” means any person or individual, natural or otherwise, and includes those person(s) or entities defined by the term “provider.”

(11) “Provider” means any individual, individual medical vendor, firm, corporation, professional association, partnership, organization, or other legal entity that provides goods or services under the Rhode Island Medicaid program, or the employee of any person or entity who, on his or her own behalf, or on the behalf of his or her employer, knowingly performs any act or is knowingly responsible for an omission prohibited by this chapter.

(12) “Recipient” means any person receiving medical assistance under the Rhode Island Medicaid program.

(13) “Records” means all documents developed by a provider and related to the provision of services reimbursed or claimed as reimbursable by the Rhode Island Medicaid program.

(14) “Rhode Island Medicaid program” means a state-administered, medical assistance program that is funded by the state and federal governments under Title XIX and Title XXI of the U.S. Social Security Act and any general or public laws and administered by the executive office of health and human services.