Part 1 General Provisions 63A-13-101 – 63A-13-102
Part 2 Office and Powers 63A-13-201 – 63A-13-205
Part 3 Investigation or Audit 63A-13-301 – 63A-13-305
Part 4 Subpoena Power 63A-13-401
Part 5 Reporting 63A-13-501 – 63A-13-502
Part 6 Miscellaneous Provisions 63A-13-601 – 63A-13-602

Terms Used In Utah Code > Title 63A > Chapter 13 - Office of Inspector General of Medicaid Services

  • Abuse: means :
    (a) an action or practice that:
    (i) is inconsistent with sound fiscal, business, or medical practices; and
    (ii) results, or may result, in unnecessary Medicaid related costs; or
    (b) reckless or negligent upcoding. See Utah Code 63A-13-102
  • Accident and health insurance: means insurance to provide protection against economic losses resulting from:
    (i) a medical condition including:
    (A) a medical care expense; or
    (B) the risk of disability;
    (ii) accident; or
    (iii) sickness. See Utah Code 31A-1-301
  • Advice and consent: Under the Constitution, presidential nominations for executive and judicial posts take effect only when confirmed by the Senate, and international treaties become effective only when the Senate approves them by a two-thirds vote.
  • Agency: means :
    (a) a person other than an individual, including a sole proprietorship by which an individual does business under an assumed name; and
    (b) an insurance organization licensed or required to be licensed under Section 31A-23a-301, 31A-25-207, or 31A-26-209. See Utah Code 31A-1-301
  • Allegation: something that someone says happened.
  • Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
  • Application: means a document:
    (a) 
    (i) completed by an applicant to provide information about the risk to be insured; and
    (ii) that contains information that is used by the insurer to evaluate risk and decide whether to:
    (A) insure the risk under:
    (I) the coverage as originally offered; or
    (II) a modification of the coverage as originally offered; or
    (B) decline to insure the risk; or
    (b) used by the insurer to gather information from the applicant before issuance of an annuity contract. See Utah Code 31A-1-301
  • Attachment: A procedure by which a person's property is seized to pay judgments levied by the court.
  • Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
  • Bequest: Property gifted by will.
  • Binder: means the same as that term is defined in Section 31A-21-102. See Utah Code 31A-1-301
  • Casualty insurance: means liability insurance. See Utah Code 31A-1-301
  • Certificate: means evidence of insurance given to:
    (a) an insured under a group insurance policy; or
    (b) a third party. See Utah Code 31A-1-301
  • Claimant: means a person that:
    (a) provides a service; and
    (b) submits a claim for Medicaid reimbursement for the service. See Utah Code 63A-13-102
  • Common law: The legal system that originated in England and is now in use in the United States. It is based on judicial decisions rather than legislative action.
  • Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
  • Contract: A legal written agreement that becomes binding when signed.
  • Creditor: means a person, including an insured, having a claim, whether:
    (a) matured;
    (b) unmatured;
    (c) liquidated;
    (d) unliquidated;
    (e) secured;
    (f) unsecured;
    (g) absolute;
    (h) fixed; or
    (i) contingent. See Utah Code 31A-1-301
  • Deed: The legal instrument used to transfer title in real property from one person to another.
  • Department: means the Department of Health and Human Services created in Section 26B-1-201. See Utah Code 63A-13-102
  • Dependent: A person dependent for support upon another.
  • Devise: To gift property by will.
  • Director: means a member of the board of directors of a corporation. See Utah Code 31A-1-301
  • Disability: means a physiological or psychological condition that partially or totally limits an individual's ability to:
    (a) perform the duties of:
    (i) that individual's occupation; or
    (ii) an occupation for which the individual is reasonably suited by education, training, or experience; or
    (b) perform two or more of the following basic activities of daily living:
    (i) eating;
    (ii) toileting;
    (iii) transferring;
    (iv) bathing; or
    (v) dressing. See Utah Code 31A-1-301
  • Discovery: Lawyers' examination, before trial, of facts and documents in possession of the opponents to help the lawyers prepare for trial.
  • Division: means the Division of Integrated Healthcare, created in Section 26B-3-102. See Utah Code 63A-13-102
  • Donor: The person who makes a gift.
  • Employee: means :
    (a) an individual employed by an employer; or
    (b) an individual who meets the requirements of Subsection (53)(b). See Utah Code 31A-1-301
  • Endorsement: means a written agreement attached to a policy or certificate to modify the policy or certificate coverage. See Utah Code 31A-1-301
  • 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.
  • exchange: means an exchange made pursuant to Section 1035, Internal Revenue Code, as may be amended. See Utah Code 31A-21-104
  • Executive director: means the executive director of the Department of Government Operations. See Utah Code 63A-1-103
  • Extrapolation: means a method of using a mathematical formula that takes the audit results from a small sample of Medicaid claims and projects those results over a much larger group of Medicaid claims. See Utah Code 63A-13-102
  • Filed: means that a filing is:
    (i) submitted to the department as required by and in accordance with applicable statute, rule, or filing order;
    (ii) received by the department within the time period provided in applicable statute, rule, or filing order; and
    (iii) accompanied by the appropriate fee in accordance with:
    (A) Section 31A-3-103; or
    (B) rule. See Utah Code 31A-1-301
  • Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
  • Fraud: Intentional deception resulting in injury to another.
  • Fraud: means an intentional or knowing:
    (a) deception, misrepresentation, or upcoding in relation to Medicaid funds, costs, a claim, reimbursement, or services; or
    (b) violation of a provision of Sections 26B-3-1102 through 26B-3-1106. See Utah Code 63A-13-102
  • Fraud unit: means the Medicaid Fraud Control Unit of the attorney general's office. See Utah Code 63A-13-102
  • Gift: A voluntary transfer or conveyance of property without consideration, or for less than full and adequate consideration based on fair market value.
  • Group insurance policy: means a policy covering a group of persons that is issued:
    (i) to a policyholder on behalf of the group; and
    (ii) for the benefit of a member of the group who is selected under a procedure defined in:
    (A) the policy; or
    (B) an agreement that is collateral to the policy. See Utah Code 31A-1-301
  • Health care professional: means a person licensed under:
    (a) Title 58, Chapter 5a, Podiatric Physician Licensing Act;
    (b) Title 58, Chapter 16a, Utah Optometry Practice Act;
    (c) Title 58, Chapter 17b, Pharmacy Practice Act;
    (d) Title 58, Chapter 24b, Physical Therapy Practice Act;
    (e) Title 58, Chapter 31b, Nurse Practice Act;
    (f) Title 58, Chapter 40, Recreational Therapy Practice Act;
    (g) Title 58, Chapter 41, Speech-Language Pathology and Audiology Licensing Act;
    (h) Title 58, Chapter 42a, Occupational Therapy Practice Act;
    (i) Title 58, Chapter 44a, Nurse Midwife Practice Act;
    (j) Title 58, Chapter 49, Dietitian Certification Act;
    (k) Title 58, Chapter 60, Mental Health Professional Practice Act;
    (l) Title 58, Chapter 67, Utah Medical Practice Act;
    (m) Title 58, Chapter 68, Utah Osteopathic Medical Practice Act;
    (n) Title 58, Chapter 69, Dentist and Dental Hygienist Practice Act;
    (o) Title 58, Chapter 70a, Utah Physician Assistant Act; and
    (p) Title 58, Chapter 73, Chiropractic Physician Practice Act. See Utah Code 63A-13-102
  • health insurance: means insurance providing:
    (i) a health care benefit; or
    (ii) payment of an incurred health care expense. See Utah Code 31A-1-301
  • Individual: means a natural person. See Utah Code 31A-1-301
  • Injunction: An order of the court prohibiting (or compelling) the performance of a specific act to prevent irreparable damage or injury.
  • Inspector general: means the inspector general of the office, appointed under Section 63A-13-201. See Utah Code 63A-13-102
  • Insurance: includes :
    (i) a risk distributing arrangement providing for compensation or replacement for damages or loss through the provision of a service or a benefit in kind;
    (ii) a contract of guaranty or suretyship entered into by the guarantor or surety as a business and not as merely incidental to a business transaction; and
    (iii) a plan in which the risk does not rest upon the person who makes an arrangement, but with a class of persons who have agreed to share the risk. See Utah Code 31A-1-301
  • Insured: means a person to whom or for whose benefit an insurer makes a promise in an insurance policy and includes:
    (i) a policyholder;
    (ii) a subscriber;
    (iii) a member; and
    (iv) a beneficiary. See Utah Code 31A-1-301
  • Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
  • Liabilities: The aggregate of all debts and other legal obligations of a particular person or legal entity.
  • Liability insurance: includes :
    (i) vehicle liability insurance;
    (ii) residential dwelling liability insurance; and
    (iii) making inspection of, and issuing a certificate of inspection upon, an elevator, boiler, machinery, or apparatus of any kind when done in connection with insurance on the elevator, boiler, machinery, or apparatus. See Utah Code 31A-1-301
  • Life insurance: means :
    (i) insurance on a human life; and
    (ii) insurance pertaining to or connected with human life. See Utah Code 31A-1-301
  • Life settlement: is a s defined in Section 31A-36-102. See Utah Code 31A-21-104
  • Member: means a person having membership rights in an insurance corporation. See Utah Code 31A-1-301
  • Mortgage: The written agreement pledging property to a creditor as collateral for a loan.
  • Mortgagee: The person to whom property is mortgaged and who has loaned the money.
  • Office: means the Office of Inspector General of Medicaid Services, created in Section 63A-13-201. See Utah Code 63A-13-102
  • Order: means an order of the commissioner. See Utah Code 31A-1-301
  • Oversight: Committee review of the activities of a Federal agency or program.
  • Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
  • Person: means :Utah Code 68-3-12.5
  • Person: includes :
    (a) an individual;
    (b) a partnership;
    (c) a corporation;
    (d) an incorporated or unincorporated association;
    (e) a joint stock company;
    (f) a trust;
    (g) a limited liability company;
    (h) a reciprocal;
    (i) a syndicate; or
    (j) another similar entity or combination of entities acting in concert. See Utah Code 31A-1-301
  • Policy: includes a service contract issued by:
    (i) a motor club under Chapter 11, Motor Clubs;
    (ii) a service contract provided under Chapter 6a, Service Contracts; and
    (iii) a corporation licensed under:
    (A) Chapter 7, Nonprofit Health Service Insurance Corporations; or
    (B) Chapter 8, Health Maintenance Organizations and Limited Health Plans. See Utah Code 31A-1-301
  • Policyholder: means a person who controls a policy, binder, or oral contract by ownership, premium payment, or otherwise. See Utah Code 31A-1-301
  • Premium: includes , however designated:
    (i) an assessment;
    (ii) a membership fee;
    (iii) a required contribution; or
    (iv) monetary consideration. See Utah Code 31A-1-301
  • Probate: Proving a will
  • Process: means a writ or summons issued in the course of a judicial proceeding. See Utah Code 68-3-12.5
  • producer: means a person licensed or required to be licensed under the laws of this state to sell, solicit, or negotiate insurance. See Utah Code 31A-1-301
  • Property: includes both real and personal property. See Utah Code 68-3-12.5
  • Property insurance: means insurance against loss or damage to real or personal property of every kind and any interest in that property:
    (i) from all hazards or causes; and
    (ii) against loss consequential upon the loss or damage including vehicle comprehensive and vehicle physical damage coverages. See Utah Code 31A-1-301
  • Provider: means a person that provides:
    (a) medical assistance, including supplies or services, in exchange, directly or indirectly, for Medicaid funds; or
    (b) billing or recordkeeping services relating to Medicaid funds. See Utah Code 63A-13-102
  • Rate: means :
    (i) the cost of a given unit of insurance; or
    (ii) for property or casualty insurance, that cost of insurance per exposure unit either expressed as:
    (A) a single number; or
    (B) a pure premium rate, adjusted before the application of individual risk variations based on loss or expense considerations to account for the treatment of:
    (I) expenses;
    (II) profit; and
    (III) individual insurer variation in loss experience. See Utah Code 31A-1-301
  • Remainder: An interest in property that takes effect in the future at a specified time or after the occurrence of some event, such as the death of a life tenant.
  • Rider: means an endorsement to:
    (a) an insurance policy; or
    (b) an insurance certificate. See Utah Code 31A-1-301
  • Security: means a:
    (i) note;
    (ii) stock;
    (iii) bond;
    (iv) debenture;
    (v) evidence of indebtedness;
    (vi) certificate of interest or participation in a profit-sharing agreement;
    (vii) collateral-trust certificate;
    (viii) preorganization certificate or subscription;
    (ix) transferable share;
    (x) investment contract;
    (xi) voting trust certificate;
    (xii) certificate of deposit for a security;
    (xiii) certificate of interest of participation in an oil, gas, or mining title or lease or in payments out of production under such a title or lease;
    (xiv) commodity contract or commodity option;
    (xv) certificate of interest or participation in, temporary or interim certificate for, receipt for, guarantee of, or warrant or right to subscribe to or purchase any of the items listed in Subsections (171)(a)(i) through (xiv); or
    (xvi) another interest or instrument commonly known as a security. See Utah Code 31A-1-301
  • Settlement: Parties to a lawsuit resolve their difference without having a trial. Settlements often involve the payment of compensation by one party in satisfaction of the other party's claims.
  • Small employer: means , in connection with a health benefit plan and with respect to a calendar year and to a plan year, an employer who:
    (i) 
    (A) employed at least one but not more than 50 eligible employees on business days during the preceding calendar year; or
    (B) if the employer did not exist for the entirety of the preceding calendar year, reasonably expects to employ an average of at least one but not more than 50 eligible employees on business days during the current calendar year;
    (ii) employs at least one employee on the first day of the plan year; and
    (iii) for an employer who has common ownership with one or more other employers, is treated as a single employer under 26 U. See Utah Code 31A-1-301
  • State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
  • Statute of limitations: A law that sets the time within which parties must take action to enforce their rights.
  • Subpoena: A command to a witness to appear and give testimony.
  • Title insurance: means the insuring, guaranteeing, or indemnifying of an owner of real or personal property or the holder of liens or encumbrances on that property, or others interested in the property against loss or damage suffered by reason of liens or encumbrances upon, defects in, or the unmarketability of the title to the property, or invalidity or unenforceability of any liens or encumbrances on the property. See Utah Code 31A-1-301
  • Trustee: means "director" when referring to the board of directors of a corporation. See Utah Code 31A-1-301
  • Trustee: A person or institution holding and administering property in trust.
  • United States: includes each state, district, and territory of the United States of America. See Utah Code 68-3-12.5
  • Upcoding: means assigning an inaccurate billing code for a service that is payable or reimbursable by Medicaid funds, if the correct billing code for the service, taking into account reasonable opinions derived from official published coding definitions, would result in a lower Medicaid payment or reimbursement. See Utah Code 63A-13-102
  • Vehicle liability insurance: means insurance against liability resulting from or incident to ownership, maintenance, or use of a land vehicle or aircraft, exclusive of a vehicle comprehensive or vehicle physical damage coverage described in Subsection (155). See Utah Code 31A-1-301
  • Waste: includes an activity that:
    (i) does not constitute abuse or necessarily involve a violation of law; and
    (ii) relates primarily to mismanagement, an inappropriate action, or inadequate oversight. See Utah Code 63A-13-102
  • Writing: includes :Utah Code 68-3-12.5