§ 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.