C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER C—MEDICAL ASSISTANCE PROGRAMS › PART 455—PROGRAM INTEGRITY: MEDICAID

42 C.F.R. § 455.1

Basis and scope

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This part sets forth requirements for a State fraud detection and investigation program, and for disclosure of information on ownership and control.

(a) Under the authority of sections 1902(a)(4), 1903(i)(2), and 1909 of the Social Security Act, Subpart A provides State plan requirements for the identification, investigation, and referral of suspected fraud and abuse cases. In addition, the subpart requires that the State—

(1) Report fraud and abuse information to the Department; and

(2) Have a method to verify whether services reimbursed by Medicaid were actually furnished to beneficiaries.

(b) Subpart B implements sections 1124, 1126, 1902(a)(36), 1903(i)(2), and 1903(n) of the Act. It requires that providers and fiscal agents must agree to disclose ownership and control information to the Medicaid State agency.

(c) Subpart C implements section 1936 of the Act. It establishes the Medicaid Integrity Program under which the Secretary will promote the integrity of the program by entering into contracts with eligible entities to carry out the activities of subpart C.

[51 FR 34787, Sept. 30, 1986, as amended at 72 FR 67655, Nov. 30, 2007]
Notes of Decisions
Cited in 6 cases, 1995–2019 · leading case: Goldstar Medical Services, Inc. v. Department of Social Services
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Goldstar Medical Services, Inc. v. Department of Social Services (2008) conn “” See 42 C.F.R. § 455.12 . Additionally, 42 C.F.”
Village Villa v. Kansas Health Policy Authority (2013) kan “30-10-ia(a)(9) is found in 42 C.F.R. § 455.1 et seq. (2006), which sets forth requirements for a state fraud detection and investigation program and for disclosure of information on ownership and control.”
Malloy v. State (2013) ga “42 CFR § 455.1 et seq. Chapter 403 of DCH’s 2010 provider manual sets forth the responsibilities of the Program Integrity (PI) Section of the Office of the Inspector General relating to its investigation of possible fraud or abuse cases and specifically provides that “[t]he…”
Costello v. Geiser (1995) ny “To that end, States are required, among other things, to adopt procedures to prevent fraud, abuse, unnecessary or inappropriate use of Medicaid services and excess payments (42 CFR 455.1, 456.3, 456.23). Each participating State must also develop its own Medicaid plan and…”
Bergeron v. Department of Health Services (1999) calctapp “Code, § 14107; see also 42 C.F.R. § 455.1 (1998).) The Department was never in a position to adjudicate the validity of the fraud allegations.”
MERCER COUNTY CHILDREN'S MEDICAL DAYCARE, LLC VS. DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES (DIVISION OF MEDICA (2019) njsuperctappdiv “See 42 C.F.R. § 455.1 to -.3. Once approved, the state must follow the plan, or risk losing federal funding.”
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