10a NCAC 22F .0202        INVESTIGATION

(a)  The Division will publish methods and procedures for the control of provider fraud, abuse, error, and overutilization.

(b)  There shall be a preliminary investigation of all complaints received or aberrant practices detected, until it is determined:

(1)           whether there are sufficient findings to warrant a full investigation;

(2)           whether there is sufficient evidence to warrant referring the case for civil and/or criminal fraud action;

(3)           whether there is insufficient evidence to support the allegation(s) and the case may be closed.

(c)  There shall be a full investigation if the preliminary findings support the conclusion of possible fraud until:

(1)           the case is referred to the appropriate law enforcement agency;

(2)           the case is found to be one of program abuse subject to administrative action;

(3)           the case is closed for insufficient evidence of fraud or abuse; or

(4)           the provider is found not to have abused or defrauded the program.


History Note:        Authority G.S. 108A‑25(b); 108A‑63; 42 U.S.C. 1396(b) et seq.; 42 C.F.R. Part 455;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. May 1, 1984.