Mich. Admin. Code R. 792.10904

Current through Vol. 24-22, December 15, 2024

Section R. 792.10904 - Definitions

Rule 904.

(1) "Adverse action" includes, but is not limited to, all of the following:

(a) A suspension or termination of provider participation in the medical assistance program.

(b) A denial of an applicant's request for participation in the medical assistance program.

(c) A denial, revocation, or suspension of a license or certification issued by the agency to allow a facility to operate.

(d) The reduction, suspension, or adjustment of provider payments.

(e) Retroactive adjustments following the audit or review and determination of the daily reimbursement rates for institutional providers.

(2) "Applicant" means an individual, firm, corporation, association, agency, institution, or other legal entity that has made formal application to participate in the medical assistance program as a provider.

(3) "Delegate" means a person who is authorized to act on behalf of the medical services administration.

(4) "Department" means the Michigan department of community health, its officials, or agents.

(5) "Director" means the director of the Michigan department of community health.

(6) "Final determination notice" means a notice of an adverse action that includes the action to be taken; the date of the proposed action; the reason for the action; the statute, rule, or guideline under which the action is taken; and the right to a hearing.

(7) "Hearing authority" means the person appointed by the director to decide appeals from decisions of an administrative law judge.

(8) "Medical assistance program" means the department's program to provide for medical assistance established by section 105 of 1939 PA 280, MCL 400.105, and title XIX of the federal Social Security Act, 42 U.S.C. section 1396, et seq.

(9)"Medical services administration" means the unit within the department of community health created by section 105 of 1939 PA 28, MCL 400.105, and title XIX of the federal social security act, 42 U.S.C. A§ 1396.

(10)"Medical services administration representative" means a person, agency, or entity authorized to review the patient care rendered by a provider or applicant or that is authorized to make audits and reviews of the records, procedures, reports, accounting methods, and billing practices of the provider or applicant, as well as the propriety of these documents or actions.

(11) "Notice," when notification by the department is indicated or required, means notice that meets the requirements of section 71(2) of the act, MCL 24.271(2). Notification shall be by certified or registered mail, with return receipt requested, to the last address of the provider or other party on file with the department.

(12) "Provider" means an individual, firm, corporation, association, agency, institution, or other legal entity which is providing, or has been approved to provide, medical assistance to a recipient pursuant to the medical assistance program.

(13) "Recipient" means an individual receiving medical assistance through the department.

Mich. Admin. Code R. 792.10904

2015 MR 1, Eff. Jan. 15, 2015