[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR455.15]



[Page 333]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 455_PROGRAM INTEGRITY: MEDICAID--Table of Contents

 

   Subpart A_Medicaid Agency Fraud Detection and Investigation Program

 

Sec.  455.15  Full investigation.



    If the findings of a preliminary investigation give the agency 

reason to believe that an incident of fraud or abuse has occurred in the 

Medicaid program, the agency must take the following action, as 

appropriate:

    (a) If a provider is suspected of fraud or abuse, the agency must--

    (1) In States with a State Medicaid fraud control unit certified 

under subpart C of part 1002 of this title, refer the case to the unit 

under the terms of its agreement with the unit entered into under Sec.  

1002.309 of this title; or

    (2) In States with no certified Medicaid fraud control unit, or in 

cases where no referral to the State Medicaid fraud control unit is 

required under paragraph (a)(1) of this section, conduct a full 

investigation or refer the case to the appropriate law enforcement 

agency.

    (b) If there is reason to believe that a recipient has defrauded the 

Medicaid program, the agency must refer the case to an appropriate law 

enforcement agency.

    (c) If there is reason to believe that a recipient has abused the 

Medicaid program, the agency must conduct a full investigation of the 

abuse.



[48 FR 3756, Jan. 27, 1983, as amended at 51 FR 34788, Sept. 30, 1986]