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MS 1240 (1) Volume 1 – General Administration MS 1240 – R. 7/1/25 – OMTL-674 Medical Assistance Claims A. Medical Assistance (MA) claims occur when a recipient or responsible party, age 18 or older, causes a financial loss to Medicaid by: 1. Deliberately making false or misleading statements in order to obtain MA benefits. 2. Allowing an individual other than those listed on the Kentucky Health card to obtain health care benefits by use of the household’s Kentucky Health card; or 3. Inappropriately using a covered service (e.g., using Non-Emergency Medical Transportation to go to work, etc.). B. When an overpayment of MA occurs due to suspected fraudulent actions: 1. [Field staff will complete a manual Family Support Claim Referral task on the Integrated Eligibility and Enrollment System (IEES). 2. A Regional Claims Worker (RCW) will review the MA claim referral and determine if there has been an overpayment of MA benefits. 3. The RCW rejects the MA claim referral on the system and refers the suspected MA claim to the Office of Inspector General (OIG). In situations where the RCW determines there is no overpayment, the RCW will reject the referral on the system and thoroughly comment. 4. When a companion case is suspected of fraud, involving at least one month of MA ineligibility, all cases must be referred to OIG regardless of the dollar amount. 5. Enter comments on the IEES regarding the referral to OIG on all associated cases and/or claims. 6. Complete form Claim/MA-1, Medical Assistance Eligibility Summary, indicating the eligibility status for each household member. OIG will obtain the dollar amount of Medicaid usage for each ineligible month. This will be added to the overpaid benefits from the other programs to determine if prosecution will be pursued.] C. A Medical Assistance claim is entered on IEES only when the claim is adjudicated through the court. If OIG determines the medical card was not used during the ineligible period or fraud cannot be established, there is no claim on IEES. D. Payments on Medical Assistance claims are handled by the Claims Management Section (CMS). OIG may recommend the collection of