Credible allegation of fraud definition

Credible allegation of fraud means the Contractor has investigated an allegation of fraud and concluded that the existence of fraud is more probable than not. (42 C.F.R. § 455.2).

Credible allegation of fraud means an allegation for fraud, which has been verified by the Authority or delegate, from any source, including but not limited to: fraud hotline complaints, claims data mining, and patterns identified through provider audits, civil false claims cases, and law enforcement investigations. Allegations are considered to be credible when they have the indicia of reliability and the Agency has reviewed all allegations, facts and evidence carefully and acts judiciously on a case-by-case basis.¶

Credible allegation of fraud means an allegation which has been verified by the department.

Examples of Credible allegation of fraud in a sentence

• 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.

• Upon notification by the Department that a Provider has been placed on a payment suspension due to a Credible Allegation of Fraud pursuant to 42 CFR § 455.23, CONTRACTOR must suspend payments to any Providers and/or administrative entities involved.

• Suspension of Payment Based on Credible Allegation of Fraud The CONTRACTOR must have a provision for suspension of payments to a Provider for which the Department determines there is a Credible Allegation of Fraud in accordance with 42 CFR § 455.23.

• Individuals or Entities Pending Fraud Investigation Non-Emergency items or service furnished by an individual or entity to whom the State, or the CONTRACTOR at the direction of the State, has failed to suspend payments during any period when there is a pending investigation of a Credible Allegation of Fraud against the individual or entity, unless the State determines there is good cause to not suspend such payments.

• Suspension of Payment for Credible Allegation – In accordance with § 42 CFR 455.23 Suspension of payment in cases of fraud, means that all Medicaid payments to a Provider are suspended after the agency determines there is a Credible Allegation of Fraud for which an investigation is pending under the Medicaid Program against an individual or entity unless the agency has good cause to not suspend payments or to suspend payment only in part.

More Definitions of Credible allegation of fraud

Credible allegation of fraud means an allegation of fraud, which has been verified by HCA, has indicia of reliability and HCA has reviewed all allegations, facts, and evidence carefully and acts judiciously on a case-by-case basis (42 C.F.R. § 455.2).

Credible allegation of fraud means an allegation

Credible allegation of fraud means an accusation of fraud as defined in 5164.36 of the Revised Code.

Credible allegation of fraud means an allegation, which has been verified by the state, from any source, including but not limited to the following:

Credible allegation of fraud means an allegation of fraud that has been verified by the state. An allegation is considered to be credible when the commission has:

Credible allegation of fraud means an allegation for fraud, which has been verified by the Authority

Credible allegation of fraud. Contractor has investigated an Allegation of Fraud and concluded that the existence of Fraud is more probable than not. “Critical Event(s)”: The events listed as such in Exhibit A. “Critical Service(s): The Services listed as such in Exhibit A.