New Mexico Statutes 27-11-2. Definitions
As used in the Medicaid Provider and Managed Care Act: A. “claim” means a request for payment for services;
Terms Used In New Mexico Statutes 27-11-2
- Allegation: something that someone says happened.
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Fraud: Intentional deception resulting in injury to another.
B. “clean claim” means a claim for reimbursement that:
(1) contains substantially all the required data elements necessary for accurate adjudication of the claim without the need for additional information from the medicaid provider or subcontractor;
(2) is not materially deficient or improper, including lacking substantiating documentation required by medicaid; and
(3) has no particular or unusual circumstances that require special treatment or that prevent payment from being made in due course on behalf of medicaid;
C. “credible” means having indicia of reliability after the state has reviewed all allegations, facts and evidence carefully and acted judiciously on a case-by-case basis;
D. “credible allegation of fraud” means an allegation that has been verified by the state from any source, including fraud hotline complaints, claims data mining and provider audits;
E. “department” means the human services department [health care authority department];
F. “fraud” means any act that constitutes fraud under state or federal law;
G. “managed care organization” means a person eligible to enter into risk-based prepaid capitation agreements with the department to provide health care and related services;
H. “medicaid” means the medical assistance program established pursuant to Title 19 of the federal Social Security Act and regulations issued pursuant to that act;
I. “medicaid provider” means a person that provides medicaid-related services to recipients;
J. “overpayment” means an amount paid to a medicaid provider or subcontractor in excess of the medicaid allowable amount, including payment for any claim to which a medicaid provider or subcontractor is not entitled;
K. “person” means an individual or other legal entity;
L. “recipient” means a person whom the department has determined to be eligible to receive medicaid-related services;
M. “secretary” means the secretary of human services; and
N. subcontractor” means a person that contracts with a medicaid provider or a managed care organization to provide medicaid-related services to recipients.