Provider abuse definition

Provider abuse means provider practices that are inconsistent with sound fiscal, business, or medical practices, and that result in unnecessary cost to the Medicaid program, that result in reimbursement for services that are not medically necessary or are excessive, or that fail to meet professionally recognized standards for health care.

Examples of Provider abuse in a sentence

  • HEALTH MANAGEMENT PROGRAMS Subject to the following, the Vendor {Contractor} shall employ an UM program to ensure appropriateness of care and to control Provider abuse.

Related to Provider abuse

  • Provider agreement means the signed, written, contractual agreement between the department and the provider of services or goods.

  • Provider agency means a funded organization under contract with the Children’s Board to deliver and provide social services and supports to children and families of Hillsborough County, FL.

  • Provider Agreements means all participation, provider and reimbursement agreements or arrangements now or hereafter in effect for the benefit of Tenant or any Manager in connection with the operation of any Facility relating to any right of payment or other claim arising out of or in connection with Tenant’s participation in any Third Party Payor Program.

  • Provider network means an affiliated group of varied health care providers that is established to provide a continuum of health care services to individuals;

  • Medicare Provider Agreement means an agreement entered into between CMS or other such entity administering the Medicare program on behalf of CMS, and a health care provider or supplier under which the health care provider or supplier agrees to provide items and services for Medicare patients in accordance with the terms of the agreement and Medicare Regulations.

  • Provider Service means a Provider’s hosted online services (if any) as described in the Solution Exhibit which is provided by Provider to Customers located in the Territory through remote access via the Internet as part of the BPO Service. A Provider Platform Application shall be considered a Provider Service.

  • Provider Enrollment means an agreement between the Department and a Medicaid provider to provide room and board and deliver care and services to a Medicaid eligible individual in an adult foster home for compensation.

  • Medicaid Provider Agreement means an agreement entered into between a state agency or other such entity administering the Medicaid program and a health care provider or supplier under which the health care provider or supplier agrees to provide services for Medicaid patients in accordance with the terms of the agreement and Medicaid Regulations.

  • Provider Organization means a group practice, facility, or organization that is:

  • Provider fee means the consideration paid for a service contract.

  • Provider Manual means a working document, including but not limited to BCBSM published bulletins and provider notices, that provide specific guidelines and direction by which providers may meet their contractual responsibility as described in this Agreement. Provider Manuals are published on web-DENIS.

  • Provider panel means those providers with which a carrier contracts to provide health care services

  • Primary Care Provider (PCP) means a health care professional who is contracted with BCBSAZ as a PCP and generally specializes in or focuses on the following practice areas: internal medicine, family practice, general practice, pediatrics or any other classification of provider approved as a PCP by BCBSAZ. Your benefit plan does not require you to have a PCP or to have a PCP authorize specialist referrals.

  • Provider of health care means a physician or physician assistant licensed pursuant to chapter 630, 630A or 633 of NRS, perfusionist, dentist, licensed nurse, dispensing optician, optometrist, practitioner of respiratory care, registered physical therapist, podiatric physician, licensed psychologist, licensed audiologist, licensed speech-language pathologist, licensed hearing aid specialist, licensed marriage and family therapist, licensed clinical professional counselor, chiropractor, licensed dietitian or doctor of Oriental medicine in any form.

  • Provider is any individual or company that provides professional or technical services.

  • Enhanced Service Provider (ESP means the provider of enhanced services, as those services are defined in 47 CFR Section 64.702.

  • Mental health services provider means an individual, licensed or unlicensed, who performs or purports to perform mental health services, including a:

  • Local Service Provider (LSP means the LEC that provides retail local Exchange Service to an End User. The LSP may or may not provide any physical network components to support the provision of that End User’s service.

  • Provider Number means an identifying number issued to each homecare worker who is enrolled as a provider through the Department.

  • Behavioral health provider means a person licensed under 34 chapter 18.57, 18.57A, 18.71, 18.71A, 18.83, 18.205, 18.225, or 18.79

  • Provider contract means any contract between a provider and a carrier (or a carrier's network,

  • Service Animal means an animal that is required by a person with a disability for assistance and is certified, in writing, as having been trained by a professional service animal institution to assist a person with a disability and which is properly harnessed in accordance with standards established by a professional service animal institution.

  • Providers means individuals or organizations --------- licensed to practice dentistry (including specialists) as well as other dental professionals who provide ancillary reimbursable dental services.

  • Acute care hospital means a Hospital that provides Acute Care Services. Adjudicate means to deny or pay a Clean Claim. Administrative Services see MCO Administrative Services. Administrative Services Contractor see HHSC Administrative Services Contractor.

  • Medicaid Certification means a certification by a state agency or other entity responsible for certifying Medicaid providers and suppliers that a health care provider or supplier is in compliance with all the conditions of participation set forth in the Medicaid Regulations.

  • Emergency medical services provider means a person who has received formal training in prehospital and emergency care, and is licensed to attend any person who is ill or injured or who has a disability. Police officers, firefighters, funeral home employees and other persons serving in a dual capacity one of which meets the definition of “emergency medical services provider” are “emergency medical services providers” within the meaning of this chapter.