Common use of Suspected Fraud Reporting Clause in Contracts

Suspected Fraud Reporting. 1. Provider Fraud and Abuse a. Upon detection of a potential or suspected fraudulent claim submitted by a provider, the Health Plan shall file a report with the Health Plan’s analyst at the Agency’s Bureau of Managed Health Care and MPI. The report shall contain at a minimum: (1) The name of the provider; (2) The assigned Medicaid provider number and the tax identification number; (3) A description of the suspected fraudulent act; and 2. Enrollee Fraud a. Upon detection of all instances of fraudulent claims or acts by an Enrollee, the Health Plan shall file a report with the Health Plan’s analyst at the Agency’s Bureau of Managed Health Care and MPI. b. The report shall contain, at a minimum: (1) The name of the Enrollee, (2) The Enrollee’s Health Plan identification number, (3) The Enrollee’s Medicaid identification number, (4) A description of the suspected fraudulent act, and 3. Failure to report instances of suspected Fraud and Abuse is a violation of law and subject to the penalties provided by law.