Family and Children's Medicaid MA-3535 RECIPIENT FRAUD AND ABUSE POLICY AND PROCEDURES

II. LEGAL RESPONSIBILITY AND REFERENCES

Both the state and the county departments of social services have a legal obligation to assure proper administration of public funds and an obligation to take necessary legal steps in cases of fraud or misrepresentation. This obligation rests on the efficiency, thoroughness and integrity of the processes by which initial and continuing eligibility are determined.

A. Social Security Act, Title XIX, Section 1909 and the implementing Federal Regulations 42 CFR Part 455 entitled "Program Integrity" set forth the requirements for the control of fraud and abuse in the Medicaid program by the state Medicaid agency, the Division of Medical Assistance (DMA).

B. North Carolina Administrative Code 10 NCAC 22F.0103 sets forth the procedures to prevent, detect, investigate, report, identify and collect all improper payments, and to impose administrative measures for the control of fraud, abuse and over-utilization practices by providers and recipients.

C. North Carolina Administrative Code 10 NCAC 22F.0700 contains procedures established by DMA regarding recipient fraud and abuse. This Section contains requirements for the prevention, detection, investigation, referral, prosecution, and recoupment of overpayments, and for the reporting of fraud, abuse and over-utilization. These procedures are supervised by DMA and administered by each county dss. Also included are the procedures for the equitable distribution of overpayments collected in cases involving overpayments in more than one assistance program.

REISSUED 7/01/08 - CHANGE NO. 11-08