Title 42, Part 455 — Program Integrity: Medicaid

Basis and scope.

Definitions.

Other applicable regulations.

State plan requirement.

Methods for identification, investigation, and referral.

Preliminary investigation.

Full investigation.

Resolution of full investigation.

Reporting requirements.

Provider's statements on claims forms.

Provider's statement on check.

Beneficiary verification procedure.

Cooperation with State Medicaid fraud control units.

Suspension of payments in cases of fraud.

Purpose.

Definitions.

Determination of ownership or control percentages.

State plan requirement.

Disclosure by Medicaid providers and fiscal agents: Information on ownership and control.

Disclosure by providers: Information related to business transactions.

Disclosure by providers: Information on persons convicted of crimes.

Disclosure of affiliations.

Basis and scope.

Limitation on contractor liability.

Eligibility requirements.

Medicaid integrity audit program contractor functions.

Awarding of a contract.

Renewal of a contract.

Conflict of interest.

Conflict of interest resolution.

Purpose.

Definitions.

Condition for Federal financial participation (FFP).

Purpose.

State plan requirements.

Enrollment and screening of providers.

Verification of provider licenses.

Revalidation of enrollment.

Termination or denial of enrollment.

Termination periods and termination database periods.

Reactivation of provider enrollment.

Appeal rights.

Site visits.

Criminal background checks.

Federal database checks.

National Provider Identifier.

Screening levels for Medicaid providers.

Other State screening methods.

Application fee.

Temporary moratoria.

Purpose.

Establishment of program.

Definitions.

Activities to be conducted by Medicaid RACs and States.

Eligibility requirements for Medicaid RACs.

Payments to RACs.

Medicaid RAC provider appeals.

Federal share of State expense of the Medicaid RAC program.

Exceptions from Medicaid RAC programs.

Applicability to the territories.