10A NCAC 22F .0103       FUNCTIONS

(a)  The Division shall develop, implement and maintain methods and procedures for preventing, detecting, investigating, reviewing, hearing, referring, reporting, and disposing of cases involving fraud, abuse, error, overutilization or the use of medically unnecessary or medically inappropriate services.

(b)  The Division shall institute methods and procedures to:

(1)           receive and process complaints and allegations of provider and recipient aberrant practices;

(2)           perform preliminary and full investigations to collect facts, data, and information;

(3)           analyze and evaluate data and information to establish facts and conclusions concerning provider and recipient practices;

(4)           make administrative decisions affecting providers, including but not limited to suspension from the Medicaid program;

(5)           recoup improperly paid claims;

(6)           establish remedial measures including but not limited to monitoring programs;

(7)           conduct administrative review or, when legally necessary, hearings except as provided in Subparagraph (b)(8) of this Rule;

(8)           refer for provider peer review those cases involving questions of professional practice.


History Note:        Authority G.S. 108A‑25(b); 108A‑63; 108A‑64; 42 C.F.R. 455, Subpart A;

Eff. May 1, 1984;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.