Allegation of Fraud definition

Allegation of Fraud means an unproved assertion: an assertion, especially relating to wrongdoing or misconduct on the part of the individual. An allegation has yet to be proved or supported by evidence. An Allegation of Fraud is an allegation, from any source, including but not limited to the following:

Allegation of Fraud means any form of communication from a party which implies fraudulent activity.

Allegation of Fraud means an unproved assertion: an assertion, especially relating to wrongdoing or misconduct on the part of the Individual. An allegation has yet to be proved or supported by evidence. Allegations may come from any source, including but not limited to, fraud (Hotline) complaints, claims data mining, and patterns identified through Contractor audits, civil false claims cases, and law enforcement investigations.

Examples of Allegation of Fraud in a sentence

• The Provider Notice form must be accompanied by the MCO’s complete investigative file, including but not limited to as applicable, preliminary investigation results, interviews, all records or documents collected, line by line review findings that substantiate any under or Overpayment, evidence supporting a Credible Allegation of Fraud, reviewer/investigative notes, Provider enrollment and Credentialing documents, related complaints, related data analysis, and any applicable repayment history.

• PI will evaluate the allegation and determine whether a Credible Allegation of Fraud (CAF) exists.

• Payment Suspension in Cases of a Credible Allegation of Fraud In cases where SCDHHS suspends a provider’s payments due to a credible allegation of fraud, it will also direct any MCO(s) who subcontract with the provider to likewise suspend that provider’s payments.

• Credible Allegation of Fraud: Any allegation of Fraud that has been verified by another State, the Government, or ASES, or otherwise has been preliminary investigated by the Contractor, as the case may be, and that has indicia of reliability that comes from any source.

• When HCA notifies the Contractor that a credible Allegation of Fraud exists, the Contractor shall follow the provisions for payment suspension contained in this Section.

More Definitions of Allegation of Fraud

Allegation of Fraud means an allegation of

Allegation of Fraud means an allegation of Medicaid fraud received by the commission from any source that has not been verified by the state, including an allegation based on:

Allegation of Fraud means any form of communication from a party that implies fraudulent activity.

Allegation of Fraud means an unproved assertion: an assertion, especially relating to wrongdoing or misconduct on the part of the Individual. An Allegation of Fraud is an allegation, from any source, including but not limited to the following: Fraud hotline complaints; Claims data mining; and Patterns identified through provider audits, civil false claims cases, and law enforcement investigations. “American Indian/Alaska Native (AI/AN)” means any individual defined at 25 USC § 1603(13), § 1603(28), or § 1679(a), or who has been determined eligible as an Indian, under 42 C.F.R. § 136.12. This means the individual is a member of a federally recognized Indian tribe or resides in an urban center and meets one or more of the following criteria: Is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the state in which they reside, or who is descendant, in the first or second degree, of any such member; Is an Eskimo or Aleut or other Alaska Native; Is considered by the Secretary of the Interior to be an Indian for any purpose; or The term AI/AN also includes an individual who is considered by the Secretary of the Interior to be an Indian for any purpose or is considered by the Secretary of Health and Human Services to be an Indian for purposes of eligibility for Indian health care services, including as a California Indian, Eskimo, Aleut, or other Alaska Native. “American Society of Addiction Medicine (ASAM)” means a professional medical society dedicated to increasing access and improving the quality of addiction treatment. “ASAM Criteria” are a comprehensive set of guidelines for determining placement, continued stay and transfer or discharge of Individuals with addiction conditions.

Allegation of Fraud means an unproved assertion: an assertion, especially relating to wrongdoing or misconduct on the part of the Individual. An Allegation of Fraud is an allegation, from any source, including but not limited to the following: Fraud hotline complaints; Claims data mining; and Patterns identified through provider audits, civil false claims cases, and law enforcement investigations. American Indian/Alaska Native (AI/AN) “American Indian/Alaska Native (AI/AN)” means any individual defined at 25 USC § 1603(13), § 1603(28), or § 1679(a), or who has been determined eligible as an Indian, under 42 C.F.R. § 136.12. This means the individual is a member of a federally recognized Indian tribe Tribe or resides in an urban center and meets one or more of the following criteria: Is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the state in which they reside, or who is descendant, in the first or second degree, of any such member; Is an Eskimo or Aleut or other Alaska Native; Is considered by the Secretary of the Interior to be an Indian for any purpose; or Is determined to be an Indian under regulations issued by the Secretary. The term AI/AN also includes an individual who is considered by the Secretary of the Interior to be an Indian for any purpose or is considered by the Secretary of Health and Human Services to be an Indian for purposes of eligibility for Indian health care services, including as a California Indian, Eskimo, Aleut, or other Alaska Native. American Society of Addiction Medicine (ASAM)

Allegation of Fraud means an allegation of 1-36 Medicaid fraud received by the commission from any source, that has 1-37 not been verified by the state, including an allegation based upon 1-38 fraud hotline complaints, claims mining data, data analysis 1-39 processes or patterns identified through provider audits, civil 1-40 false claims cases, and law enforcement investigations.

Allegation of Fraud means an unproved assertion: an assertion, especially relating to wrongdoing or misconduct on the part of the Individual.