The general assembly recognizes that data mining is an important tool that should be used for the detection of fraud and abuse in the TennCare program; therefore, it is the intention of the general assembly that:

(1) The office of inspector general shall engage in data mining relating to the receipt of medical assistance and any assistance paid for by TennCare on behalf of recipients, for the purpose of detecting fraud or abuse by recipients;

Terms Used In Tennessee Code 71-5-2513

  • Fraud: Intentional deception resulting in injury to another.
  • Fraud: means an intentional deception or misrepresentation made by a person including, but not limited to, a vendor, recipient, provider, or enrollee, with the knowledge that the deception or misrepresentation could result in some unauthorized benefit or payment to oneself or some other person. See Tennessee Code 71-5-2503
  • Inspector general: means the person who directs the office of inspector general, who shall report directly to the commissioner of finance and administration. See Tennessee Code 71-5-2503
  • Medical assistance: means payment of the cost of care, services and supplies necessary to prevent, diagnose, correct or cure conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with the person's capacity for normal activity, or threaten some significant disability and which are furnished an eligible person in accordance with the rules, regulations, and statutes governing TennCare. See Tennessee Code 71-5-2503
  • State: when applied to the different parts of the United States, includes the District of Columbia and the several territories of the United States. See Tennessee Code 1-3-105
  • TennCare: means the program administered by the single state agency, as designated by the state and CMS, pursuant to Title XIX of the Social Security Act ( 42 U. See Tennessee Code 71-5-2503
(2) The inspector general shall have prompt, continuing, and effective access to all such data in a manner that will permit effective data mining for these purposes without imposing unduly burdensome or oppressive requirements on persons or entities that provide medical assistance or any assistance paid for by TennCare; and
(3) Data mining by the office of the inspector general is not intended to alter the requirements under Title XIX of the federal Social Security Act ( 42 U.S.C. § 1395 et seq.), including, but not limited to, the requirements that the single state agency designated to administer the medicaid program must have methods and criteria for identifying suspected fraud cases, must have a method for verifying whether services billed were received, and must cooperate with the state’s medicaid fraud control unit.
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