§455.15. Full investigation.
42 C.F.R. § 455.15
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:
If a provider is suspected of fraud or abuse, the agency must—
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 § 1002.309 of this title; or
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.
If there is reason to believe that a beneficiary has defrauded the Medicaid program, the agency must refer the case to an appropriate law enforcement agency.
If there is reason to believe that a beneficiary has abused the Medicaid program, the agency must conduct a full investigation of the abuse.
Notes, amendments, and revision history
Amendments
[48 FR 3756, Jan. 27, 1983, as amended at 51 FR 34788, Sept. 30, 1986]
Authority
Authority: 42 U.S.C. 1302.
Source
Source: 43 FR 45262, Sept. 29, 1978, unless otherwise noted.
Amendments
[48 FR 3756, Jan. 27, 1983, as amended at 51 FR 34788, Sept. 30, 1986]