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COMAR 10.09.24.15

1519

State of Maryland Medical Assistance Manual Revised July 2012 SECTION VI COMMENTS

To: DHMH Medicaid Program Integrity Recipient Fraud and Abuse Unit 201 West Preston Street, Room 520 Baltimore, Maryland 21201 FAX: 410-333-5326 410-333-7194 From: DSS

Case Manager: .

Telephone: .

Re: ___________________________________________ Case Status:

Case #/Category:_________________________________

Representative/Address:__________________________________________________________________________

A. Request for an investigation involving an unreported or untimely reporting of:

A Change in Circumstance -Excluded Resources for Less than Fair Market Value

____________________________________________________________________________________________________ ____ B. (Complete if known) Had the information now known been reported in a timely manner, the recipient would have been :

with Spend-Down amount from $______________ to ________________ beginning______________ to _______________. Total Due State: $ ____________________________________

from $ ______________ to $ ______________ beginning _________________ to ___________________. from $ ______________ to $ ______________ beginning _________________ to ___________________.

Total Due State: $ _____________________________________

C.Comments:_________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ___________________

NOTE: Attach one copy of all documents relevant to the referral.

D. Checklist for Completion: Ensure the following are completed before sending this form.

_____ Completed Referral signed by a supervisor citing the case circumstance as well as suspected period of ineligibility. _____ Copy of application for eligibility period of suspected fraud. _____ Copy of all other pertinent documents (i.e. bank statements, life insurance policies, etc.) relevant to suspected fraud.

_______________ ________________ _____________ __________________ Supervisor‟s Name Signature Date Telephone Number