N.J. Admin. Code § 10:69-9.16 - Criteria for identifying cases of possible fraud

(a) Fraud is defined as obtaining or attempting to obtain Medicaid coverage to which an individual is not entitled by means of willful misrepresentation or by intentional concealment of a relevant fact. There are three basic elements that must be established:

1. The misrepresentation or concealment must have been deliberate and done knowingly. Fraud does not exist if the misrepresentation or concealment is the result of an unintentional act, a misunderstanding or mental incompetency. Distinction must also be made between intent to defraud by the individual and omission, neglect or error by the agency's representatives in securing and recording information;

2. The misrepresentation or concealment must have been undertaken for the express purpose of receiving or obtaining benefits or attempting to receive or obtain benefits; and

3. If the CWA had known the misrepresentation or concealment, or attempt to misrepresent or conceal a relevant fact, Medicaid coverage would not have been granted.

(b) The evidence to establish the points in (a) above must be factual and capable of being demonstrated in a court of law through the testimony of witnesses or by documentary evidence. Since fraud is subject to criminal action, it must be proved beyond a reasonable doubt.

Notes

N.J. Admin. Code § 10:69-9.16

Amended by 49 N.J.R. 3729(a), effective 12/4/2017