108C-2. Definitions.

The following definitions apply in this Chapter:

(1) Adverse determination. - A final decision by the Department to deny, terminate, suspend, reduce, or recoup a Medicaid payment or to deny, terminate, or suspend a provider's or applicant's participation in the Medical Assistance Program.

(2) Applicant. - An individual, partnership, group, association, corporation, institution, or entity that applies to the Department for enrollment as a provider in the North Carolina Medical Assistance Program or the North Carolina Health Insurance Program for Children.

(3) Department. - The North Carolina Department of Health and Human Services, its legally authorized agents, contractors, or vendors who acting within the scope of their authorized activities, assess, authorize, manage, review, audit, monitor, or provide services pursuant to Title XIX or XXI of the Social Security Act, the North Carolina State Plan of Medical Assistance, the North Carolina State Plan of the Health Insurance Program for Children, or any waivers of the federal Medicaid Act granted by the United States Department of Health and Human Services.

(4) Division. - The Division of Health Benefits of the Department.

(5) Final overpayment, assessment, or fine. - The amount the provider owes after appeal rights have been exhausted, which shall not include any agency decision that is being contested at the Department or the Office of Administrative Hearings or in Superior Court, provided that the Superior Court has entered a stay pursuant to the provisions of G.S. 150B-48.

(6) Health Choice. - The Health Insurance Program for Children authorized by G.S. 108A-70.25 and as set forth in the North Carolina State Plan of the Health Insurance Program for Children.

(7) Managing employee. - As defined in 42 C.F.R. 455.101.

(8) Medicaid. - The Medical Assistance program authorized by G.S. 108A-54 and as set forth in the North Carolina State Plan of Medical Assistance.

(9) Owner and/or operator. - As defined in 42 C.F.R. 455.101.

(10) Provider. - An individual, partnership, group, association, corporation, institution, or entity required to enroll in the North Carolina Medical Assistance Program or the North Carolina Health Insurance Program for Children to provide services, goods, supplies, or merchandise to a Medicaid or Health Choice recipient.

(11) Revalidation. - The reenrollment of a provider in the Medicaid or Health Choice programs as required under federal law.

(12) Secretary. - The Secretary of the Department of Health and Human Services. (2011-399, s. 1; 2018-5, s. 11H.12(b); 2019-81, s. 15(a).)