Article 11 Section 03 Fraud Referral Procedures
Table of Contents
TITLE PG CITE
Reporting Provider Fraud 110301
General 110301A
Referral Initiated 110302
Before Certification 110302A
After Certification 110302B
Referral Pending 110303
Eligible 110303A
Not Eligible 110303B
110301 Reporting Provider Fraud
110301A Informants who want to report possible provider fraud are General referred to the Provider Relations Coordinator at 8584924422
110302 Referral Initiated
110302A When workers cannot resolve inconsistencies in information Before given by an applicant they send an email with the fraud referral Certification CMS29 to the Fraud worker
If application date is Then the Fraud worker
before May 12 2008 orders the case from Records Library when appropriate
after May 12 2008 may view the case on the CMS IT system
110302B After Certification
When a worker receives
Then an email is sent to information that a beneficiary
has fraudulently received
the Fraud worker with the CMS coverage
CMS29
Note Results of the investigation must also be recorded in the case record
110303 Referral Pending
110303A Eligible If all eligibility requirements are met and the verifications are not questionable the decision to certify may not be delayed pending the response from the Fraud worker If the worker is ready to certify and the fraud referral was made at least one week before the worker calls the Fraud worker to check on the status of the investigation
110303B Not Eligible If the preponderance of evidence submitted by the applicantbeneficiary indicates ineligibility the worker will deny The applicant has the right to appeal the denial