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. § 455.21

Cooperation with State Medicaid fraud control units

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In a State with a Medicaid fraud control unit established and certified under subpart C of this part,

(a) The agency must—

(1) Refer all cases of suspected provider fraud to the unit;

(2) If the unit determines that it may be useful in carrying out the unit's responsibilities, promptly comply with a request from the unit for—

(i) Access to, and free copies of, any records or information kept by the agency or its contractors;

(ii) Computerized data stored by the agency or its contractors. These data must be supplied without charge and in the form requested by the unit; and

(iii) Access to any information kept by providers to which the agency is authorized access by section 1902(a)(27) of the Act and § 431.107 of this subchapter. In using this information, the unit must protect the privacy rights of beneficiaries; and

(3) On referral from the unit, initiate any available administrative or judicial action to recover improper payments to a provider.

(b) The agency need not comply with specific requirements under this subpart that are the same as the responsibilities placed on the unit under subpart D of this part.

(c) The agency must enter into a written agreement with the unit under which:

(1) The agency will agree to comply with all requirements of § 455.21(a);

(2) The unit will agree to comply with the requirements of § 1007.11(c) of this title; and

(3) The agency and the unit will agree to—

(i) Establish a practice of regular meetings or communication between the two entities;

(ii) Establish procedures for how they will coordinate their efforts;

(iii) Establish procedures for §§ 1007.9(e) through 1007.9(h) of this title;

(iv) Establish procedures by which the unit will receive referrals of potential fraud from managed care organizations, if applicable, either directly or through the agency, as required at § 438.608(a)(7) of this title; and

(v) Review and, as necessary, update the agreement no less frequently than every five (5) years to ensure that the agreement reflects current law and practice.

[43 FR 45262, Sept. 29, 1978, as amended at 84 FR 10713, Mar. 22, 2019]
Notes of Decisions
Cited in 3 cases, 1983–2019 · leading case: Stornanti v. Commonwealth, 451 N.E.2d 707 (Mass. 1983).
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Stornanti v. Commonwealth, 451 N.E.2d 707 (Mass. 1983). · cites it 2× “See 42 C.F.R. § 455.21 (1982); In re Grand Jury Investigation, R.”
State v. Chalice Renee Zeitner, 436 P.3d 484 (Ariz. 2019). “" 42 C.F.R. § 455.21 (a)(2)(i), (iii). It must also "make available to [f]ederal investigators or prosecutors all information in its possession concerning fraud in the provision or administration of medical assistance under the [s]tate plan.”
People v. Ekong, 582 N.E.2d 233 (Ill. App. Ct. 1991). “” 42 C.F.R. §455.21 (a)(2)(iii) (1991). Furthermore, a State plan must provide for an agreement between the medicaid agency and each provider furnishing services under the plan (including individual practitioners), in which agreement the provider agrees to: “(1) Keep any records…”
Annotations are extracted automatically from the opinions in the Syfert caselaw corpus and ranked by authority, recency, and treatment. Dots show Syfertize treatment of the citing case itself.