42 CFR 455.15 - Full investigation.

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There are 2 Updates appearing in the Federal Register for 42 CFR Part 455. View below or at eCFR (GPOAccess)
§ 455.15 Full investigation.

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:

(a) If a provider is suspected of fraud or abuse, the agency must -

(1) In States with a StateMedicaidfraud 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

(2) In States with no certified Medicaidfraud control unit, or in cases where no referral to the StateMedicaidfraud 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.

(b) 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.

(c) If there is reason to believe that a beneficiary has abused the Medicaid program, the agency must conduct a full investigation of the abuse.

[48 FR 3756, Jan. 27, 1983, as amended at 51 FR 34788, Sept. 30, 1986]

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United States Code

Title 42 published on 2015-11-28

The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 42 CFR Part 455 after this date.

  • 2016-09-20; vol. 81 # 182 - Tuesday, September 20, 2016
    1. 81 FR 64383 - Medicaid; Revisions to State Medicaid Fraud Control Unit Rules
      GPO FDSys XML | Text
      DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services, Office of Inspector General
      Proposed rule.
      To ensure consideration, comments must be delivered to the address provided below by no later than 5 p.m. Eastern Standard Time on November 21, 2016.
      42 CFR Part 455

Title 42 published on 2015-11-28.

The following are only the Rules published in the Federal Register after the published date of Title 42.

For a complete list of all Rules, Proposed Rules, and Notices view the Rulemaking tab.

  • 2016-08-03; vol. 81 # 149 - Wednesday, August 3, 2016
    1. 81 FR 51116 - Medicare, Medicaid, and Children's Health Insurance Programs: Announcement of the Provider Enrollment Moratoria Access Waiver Demonstration of Part B Non-Emergency Ground Ambulance Suppliers and Home Health Agencies in Moratoria-Designated Geographic Locations
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      DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services
      Implementation of the waiver demonstration.
      Effective July 29, 2016.
      42 CFR Parts 405, 424, and 455