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 › Subpart A—Medicaid Agency Fraud Detection and Investigation Program

42 C.F.R. § 455.13

Methods for identification, investigation, and referral

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The Medicaid agency must have—

(a) Methods and criteria for identifying suspected fraud cases;

(b) Methods for investigating these cases that—

(1) Do not infringe on the legal rights of persons involved; and

(2) Afford due process of law; and

(c) Procedures, developed in cooperation with State legal authorities, for referring suspected fraud cases to law enforcement officials.

[43 FR 45262, Sept. 29, 1978, as amended at 48 FR 3755, Jan. 27, 1983]
Notes of Decisions
Cited in 3 cases, 2002–2020 · leading case: Morcos S. Azer Doctor's Medical Laboratory, Inc. v. Kathleen Connell John Chen Steven Fujimori Joseph P. Munso Al Schade
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Morcos S. Azer Doctor's Medical Laboratory, Inc. v. Kathleen Connell John Chen Steven Fujimori Joseph P. Munso Al Schade (2002) ca9 “10 (3) to have a single state agency administer the Medi-Cal program; and (4) defendants deprived plaintiffs of their rights under 42 C.F.R. §§ 455.13 and 455.23 to due process of law and to have funds withheld only temporarily.”
Goldstar Medical Services, Inc. v. Department of Social Services (2008) conn “For example, 42 C.F.R. § 455.13 (a) requires state agencies to have in place “[mjethods and criteria for identifying suspected fraud cases .”
Lenoir v. AHCA (2020) flsd “055 is in conflict with 42 CFR § 455.13 and should be found unconstitutional.”
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