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.