[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR455.101]



[Page 335-336]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 455_PROGRAM INTEGRITY: MEDICAID--Table of Contents

 

   Subpart B_Disclosure of Information by Providers and Fiscal Agents

 

Sec.  455.101  Definitions.



    Agent means any person who has been delegated the authority to 

obligate or act on behalf of a provider.

    Disclosing entity means a Medicaid provider (other than an 

individual practitioner or group of practitioners), or a fiscal agent.

    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



[[Page 336]]



the programs established under title V, XVIII, or XX of the Act. This 

includes:

    (a) Any hospital, skilled nursing facility, home health agency, 

independent clinical laboratory, renal disease facility, rural health 

clinic, or health maintenance organization that participates in Medicare 

(title XVIII);

    (b) Any Medicare intermediary or carrier; and

    (c) Any entity (other than an individual practitioner or group of 

practitioners) that furnishes, or arranges for the furnishing of, 

health-related services for which it claims payment under any plan or 

program established under title V or title XX of the Act.

    Fiscal agent means a contractor that processes or pays vendor claims 

on behalf of the Medicaid agency.

    Group of practitioners means two or more health care practitioners 

who practice their profession at a common location (whether or not they 

share common facilities, common supporting staff, or common equipment).

    Indirect ownership interest means an ownership interest in an entity 

that has an ownership interest in the disclosing entity. This term 

includes an ownership interest in any entity that has an indirect 

ownership interest in the disclosing entity.

    Managing employee means a general manager, business manager, 

administrator, director, or other individual who exercises operational 

or managerial control over, or who directly or indirectly conducts the 

day-to-day operation of an institution, organization, or agency.

    Ownership interest means the possession of equity in the capital, 

the stock, or the profits of the disclosing entity.

    Person with an ownership or control interest means a person or 

corporation that--

    (a) Has an ownership interest totaling 5 percent or more in a 

disclosing entity;

    (b) Has an indirect ownership interest equal to 5 percent or more in 

a disclosing entity;

    (c) Has a combination of direct and indirect ownership interests 

equal to 5 percent or more in a disclosing entity;

    (d) Owns an interest of 5 percent or more in any mortgage, deed of 

trust, note, or other obligation secured by the disclosing entity if 

that interest equals at least 5 percent of the value of the property or 

assets of the disclosing entity;

    (e) Is an officer or director of a disclosing entity that is 

organized as a corporation; or

    (f) Is a partner in a disclosing entity that is organized as a 

partnership.

    Significant business transaction means any business transaction or 

series of transactions that, during any one fiscal year, exceed the 

lesser of $25,000 and 5 percent of a provider's total operating 

expenses.

    Subcontractor means--

    (a) An individual, agency, or organization to which a disclosing 

entity has contracted or delegated some of its management functions or 

responsibilities of providing medical care to its patients; or

    (b) An individual, agency, or organization with which a fiscal agent 

has entered into a contract, agreement, purchase order, or lease (or 

leases of real property) to obtain space, supplies, equipment, or 

services provided under the Medicaid agreeement.

    Supplier means an individual, agency, or organization from which a 

provider purchases goods and services used in carrying out its 

responsibilities under Medicaid (e.g., a commercial laundry, a 

manufacturer of hospital beds, or a pharmaceutical firm).

    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.



[44 FR 41644, July 17, 1979, as amended at 51 FR 34788, Sept. 30, 1986]