10A NCAC 22F .0302       INVESTIGATION

(a)  Fraud, waste, abuse, error, or practices not conforming to state and federal Medicaid laws and regulations, clinical coverage policies, or the Medicaid State Plan shall be investigated according to the provisions of Rule .0202 of this Subchapter.

(b)  A Provider Summary Report shall be prepared by the Division furnishing the full investigative findings of fact, conclusions, and recommendations.

(c)  The Division shall review the findings, conclusions, and recommendations and make a tentative decision for disposition of the case. The Division shall seek full restitution of any improper provider payments as required by 10A NCAC 22F .0601. In addition, upon determination that program abuse has occurred and based on the factors set out in Rule .0602(b) of this Subchapter, the Division may also take one or more administrative actions pursuant to Rule .0602 of this Subchapter.

(d)  The tentative decision shall be subject to the review procedures described in Section .0400 of this Subchapter.

(e)  If the investigative findings show that the provider is not licensed or certified as required by federal and State law, then the provider shall not participate in the North Carolina State Medical Assistance Program (Medicaid). The Division is required to verify provider licensure pursuant to 42 C.F.R. 455.412, which is adopted and incorporated by reference with subsequent changes or amendments and available free of charge at https://www.ecfr.gov/.

History Note:        Authority G.S. 108A‑25(b); 108A-54; 108A-54.1B; 108A-63; 108C-5; 108C-7; 42 C.F.R. 455, Subpart A; 42 CFR 455.412;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. July 1, 1988; May 1, 1984;

Readopted Eff. September 1, 2018.