New Mexico Statutes Chapter 27. Public Assistance § 27-11-2. Definitions

A. “claim” means a request for payment for services;

B. “clean claim” means a claim for reimbursement that:

C. “credible” means having indicia of reliability after the state has reviewed all allegations, facts and evidence carefully and acted judiciously on a case-by-case basis;

D. “credible allegation of fraud” means an allegation that has been verified by the state from any source, including fraud hotline complaints, claims data mining and provider audits;

E. “department” means the human services department [health care authority department];

F. “fraud” means any act that constitutes fraud under state or federal law;

G. “managed care organization” means a person eligible to enter into risk-based prepaid capitation agreements with the department to provide health care and related services;

H. “medicaid” means the medical assistance program established pursuant to Title 19 of the federal Social Security Act  1 and regulations issued pursuant to that act;

I. “medicaid provider” means a person that provides medicaid-related services to recipients;

J. “overpayment” means an amount paid to a medicaid provider or subcontractor in excess of the medicaid allowable amount, including payment for any claim to which a medicaid provider or subcontractor is not entitled;

K. “person” means an individual or other legal entity;

L. “recipient” means a person whom the department has determined to be eligible to receive medicaid-related services;

M. “secretary” means the secretary of human services; and

N. “subcontractor” means a person that contracts with a medicaid provider or a managed care organization to provide medicaid-related services to recipients.