As used in the Medicaid Provider and Managed Care Act:
A. "claim" means a request for payment for services;
B. "clean claim" means a claim for reimbursement that:
(1) contains substantially all the required data elements necessary for accurate adjudication of the claim without the need for additional information from the medicaid provider or subcontractor;
(2) is not materially deficient or improper, including lacking substantiating documentation required by medicaid; and
(3) has no particular or unusual circumstances that require special treatment or that prevent payment from being made in due course on behalf of medicaid;
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" or "authority" means the health care authority;
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 authority 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 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 authority has determined to be eligible to receive medicaid-related services;
M. "secretary" means the secretary of health care authority; and
N. "subcontractor" means a person that contracts with a medicaid provider or a managed care organization to provide medicaid-related services to recipients.