63-701 General and Definition of Fraud



This chapter provides definitions of fraud, criteria for fraud referrals and procedural instructions on when and how to initiate a fraud referral, as well as the actions required before and after initiation of a referral.



Definition of Fraud

Fraud exists when a person, on behalf of him/herself or others, knowingly and with intent to deceive or defraud:


  Makes a false statement or representation to obtain benefits, obtain a continuance or increase of benefits, or avoid a reduction of benefits;


  Fails to disclose a fact which, if disclosed, could have resulted in a denial, reduction or discontinuance of benefits;


  Accepts benefits to which he/she was not entitled, or accepted an amount of benefits knowing it is greater than the amount to which he/she is entitled; and/or


  Made statements that he/she knew to be untrue for the purpose of obtaining benefits, continuing to obtain benefits or avoiding a reduction or denial of benefits.