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