42 C.F.R. § 431.958 Definitions and use of terms.
Title 42 - Public Health
As used in this subpart, the following definitions apply: Improper payment means any payment that should not have been made or that was made in an incorrect amount (including overpayments and underpayments) under statutory, contractual, administrative, or other legally applicable requirements; and includes any payment to an ineligible recipient, any duplicate payment, any payment for services not received, any payment incorrectly denied and any payment that does not account for credits or applicable discounts. Payment means any payment to a provider, insurer, or managed care organization for a Medicaid or SCHIP recipient for which there is Medicaid or SCHIP Federal financial participation. It may also mean a direct payment to a Medicaid or SCHIP recipient in limited circumstances permitted by CMS regulation or policy. Payment error rate means an annual estimate of improper payments made under Medicaid and SCHIP equal to the sum of the overpayments (including payments to ineligible recipients) and underpayments, that is, the absolute value, expressed as a percentage of total payments made over the sampling period.
Title 42: Public Health
PART 431—STATE ORGANIZATION AND GENERAL ADMINISTRATION
Subpart Q—Requirements for Estimating Improper Payments in Medicaid and SCHIP
§ 431.958 Definitions and use of terms.
