Article 11 Section 03 Fraud Referral Procedures

 

Table of Contents

 

Title

PG Cite

Reporting Provider Fraud

11.03.01

General

11.03.01A

Referral Initiated

11.0302

Before Certification

11.0302A

After Certification

11.0302B

Referral Pending

11.03.03

Eligible

11.03.03A

Not Eligible

11.03.03B

 

 

11.03.01 Reporting Provider Fraud

 

11.03.01A
General

Informants who want to report possible provider fraud are referred to the Provider Relations Coordinator at 858-492-4422.

 

11.03.02 Referral Initiated

 

11.03.02A
Before Certification

When workers cannot resolve inconsistencies in information given by an applicant, they send an email with the fraud referral (CMS-29) 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.

 

 

11.03.02B
After Certification

 

When a worker receives information that a beneficiary…

Then an email is sent to…

has fraudulently received CMS coverage,

the Fraud worker with the CMS-29.

is misusing a CMS card,

the Fraud worker.

 

Note:  Results of the investigation must also be recorded in the case record.

 

11.03.03 Referral Pending

 

11.03.03A
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.

 

11.03.03B
Not Eligible

If the preponderance of evidence submitted by the applicant/beneficiary indicates ineligibility, the worker will deny.  The applicant has the right to appeal the denial.