Credible allegation of fraud.
Credible allegation of fraud. A credible allegation of fraud is an allegation from any source, including but not limited to the following:
(1) Fraud hotline complaints.
(2) Claims data mining.
(3) Patterns identified through provider audits, civil false claims cases, and law enforcement investigations. Allegations are considered to be credible when they have indicia of reliability.
42 CFR § 405.370
For purposes of this subpart, the following definitions apply: