[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: 42CFR455.23]



[Page 335]

 

                         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.  455.23  Withholding of payments in cases of fraud or willful 



misrepresentation.



    (a) Basis for withholding. The State Medicaid agency may withhold 

Medicaid payments, in whole or in part, to a provider upon receipt of 

reliable evidence that the circumstances giving rise to the need for a 

withholding of payments involve fraud or willful misrepresentation under 

the Medicaid program. The State Medicaid agency may withhold payments 

without first notifying the provider of its intention to withhold such 

payments. A provider may request, and must be granted, administrative 

review where State law so requires.

    (b) Notice of withholding. The State agency must send notice of its 

withholding of program payments within 5 days of taking such action. The 

notice must set forth the general allegations as to the nature of the 

withholding action, but need not disclose any specific information 

concerning its ongoing investigation. The notice must:

    (1) State that payments are being withheld in accordance with this 

provision;

    (2) State that the withholding is for a temporary period, as stated 

in paragraph (c) of this section, and cite the circumstances under which 

withholding will be terminated;

    (3) Specify, when appropriate, to which type or types of Medicaid 

claims withholding is effective; and

    (4) Inform the provider of the right to submit written evidence for 

consideration by the agency.

    (c) Duration of withholding. All withholding of payment actions 

under this section will be temporary and will not continue after:

    (1) The agency or the prosecuting authorities determine that there 

is insufficient evidence of fraud or willful misrepresentation by the 

provider; or

    (2) Legal proceedings related to the provider's alleged fraud or 

willful misrepresentation are completed.



[52 FR 48817, Dec. 28, 1987]