Common use of CONTRACT DEFINITIONS Clause in Contracts

CONTRACT DEFINITIONS. For purposes of this Contract the following definitions apply, unless otherwise specified: Abuse means Provider practices that are inconsistent with sound fiscal, business, or medical practices, and results in unnecessary cost to the Medicaid program, or in reimbursement of services that are not Medically Necessary, or that fail to meet professionally recognized standards for health care. It also includes Medicaid member practices that result in unnecessary cost to the Medicaid program. Accountable Care Organization (ACO) means a Utah Managed Care Organization (MCO) that contracts with the Department to provide medical services to Medicaid members. Actuary means an individual who meets the qualification standards established by the American Academy of Actuaries for an actuary and follows the practice standards established by the Actuarial Standards Board. In this Contract, Actuary refers to an individual who is acting on behalf of the State when used in reference to the development and certification of Capitation Rates.