What is 42 cfr 455.101

42 CFR § 455.101 - Definitions.

PCCMs will comply with disclosure requirements under paragraph c 1 of this section. A State may find that good cause exists to suspend payments in part, or to convert a payment suspension previously imposed in whole to one only in part, to an individual or entity against which there is an investigation of a credible allegation of fraud if any of the following are applicable:.

Conversely, if B owns 80 percent of the stock of a corporation which owns 5 percent of the stock of the disclosing entity, B's interest equates to a 4 percent indirect ownership interest in the disclosing entity and need not be reported. In order to determine percentage of ownership, mortgage, deed of trust, note, or other obligation, the percentage of interest owned in the obligation is multiplied by the percentage of the disclosing entity's assets used to secure the obligation.

Agent means any person who has been delegated the authority to obligate or act on behalf of a provider. Ownership interest means the possession of equity in the capital, the stock, or the profits of the disclosing entity. It sets forth State plan requirements regarding—. This includes:. CMS considers that a post-award conflict of interest has developed if, during the term of the contract, one of the following occurs:.

These competitive procedures and requirements for awarding Medicaid integrity audit program contracts are to be used as follows:. The Medicaid agency must obtain disclosures from disclosing entities, fiscal agents, and managed care entities.

These data must be supplied without charge and in the form requested by the unit; and. State Medicaid agencies must meet the following requirements:. Wholly owned supplier means a supplier whose total ownership interest is held by a provider or by a person , persons, or other entity with an ownership or control interest in a provider. The certification should also identify any data issues or other caveats that the auditor identified as impacting the results of the audit.

Each hospital that qualifies for a DSH payment in the State is allowed to retain that payment so that the payment is available to offset its uncompensated care costs for furnishing inpatient hospital and outpatient hospital services during the Medicaid State plan rate year to Medicaid eligible individuals and individuals with no source of third party coverage for the services in order to reflect the total amount of claimed DSH expenditures.

The contract between CMS and a Medicaid integrity audit program contractor specifies the functions the contractor will perform.

Other disclosing entity means any other Medicaid disclosing entity and any entity that does not participate in Medicaid , but is required to disclose certain ownership and control information because of participation in any of the programs established under title V, XVIII, or XX of the Act. In that situation, the provisions of paragraph d 3 of this section apply equally to that referral as well. Exclusion means that items or services furnished by a specific provider who has defrauded or abused the Medicaid program will not be reimbursed under Medicaid.

Indirect ownership interest means an ownership interest in an entity that has an ownership interest in the disclosing entity. Box address.