GroundRules
42 CFR 455.16: Resolution of full investigation.
Where this section sits in the code
- Title 42—Public Health
- 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
A full investigation must continue until—
(a) Appropriate legal action is initiated;
(b) The case is closed or dropped because of insufficient evidence to support the allegations of fraud or abuse; or
(c) The matter is resolved between the agency and the provider or beneficiary. This resolution may include but is not limited to—
(1) Sending a warning letter to the provider or beneficiary, giving notice that continuation of the activity in question will result in further action;
(2) Suspending or terminating the provider from participation in the Medicaid program;
(3) Seeking recovery of payments made to the provider; or
(4) Imposing other sanctions provided under the State plan.
Collected 2026-08-27T02:26:11Z. Source file · JSON