11200 Determination of Fraud

A fraud error can only be established through a finding by a court of appropriate jurisdiction. Therefore, additional steps are required before collection action may commence.

A suspected fraud error shall be referred to the Office of the Medicaid Inspector General (OMIG). The OMIG will decide whether to pursue the case in court. If a decision is made not to pursue, the claim will be labeled as Client Error and processed as such. If the claim is accepted by the OMIG for prosecution, no further action shall be taken until a decision by the court has been rendered.

Individuals should not receive notice that the case is under investigation for fraud. Client inquiries concerning the possible fraud investigation should be responded with a statement that the case is “under administrative review.” No additional information should be provided.