10a NCAC 22F .0202       INVESTIGATION

(a)  The Division shall conduct a preliminary investigation of all complaints received or allegations of fraud, waste, abuse, error, or practices not conforming to state and federal Medicaid laws and regulations, clinical coverage policies, or the Medicaid State Plan until it is determined:

(1)           whether there are sufficient findings to warrant a full investigation, as set out in Paragraph (b) of this Rule;

(2)           whether there is sufficient evidence to warrant referring the case for civil fraud investigation, criminal fraud investigation, or both; or

(3)           whether there is insufficient evidence to support the allegation(s) and the case may be closed.

(b)  There shall be a full investigation if the preliminary findings support a credible allegation of possible fraud until:

(1)           the case is found to be one of program abuse subject to administrative action, pursuant to Rule .0602 of this Subchapter;

(2)           the case is closed for insufficient evidence of fraud or abuse; or

(3)           the provider is found not to have abused or defrauded the program.


History Note:        Authority G.S. 108A‑25(b); 108A‑63; 42 U.S.C. 1396(b) et seq.; 42 C.F.R. Part 455, Subpart A;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. May 1, 1984;

Readopted Eff. July 1, 2018.