{"data":{"id":"us/42-cfr-455.15","jurisdiction":"us","citation":"42 CFR 455.15","heading":"Full investigation.","body":"If the findings of a preliminary investigation give the agency reason to believe that an incident of fraud or abuse has occurred in the Medicaid program, the agency must take the following action, as appropriate:\n(a) If a provider is suspected of fraud or abuse, the agency must—\n(1) In States with a State Medicaid fraud control unit certified under subpart C of part 1002 of this title, refer the case to the unit under the terms of its agreement with the unit entered into under § 1002.309 of this title; or\n(2) In States with no certified Medicaid fraud control unit, or in cases where no referral to the State Medicaid fraud control unit is required under paragraph (a)(1) of this section, conduct a full investigation or refer the case to the appropriate law enforcement agency.\n(b) If there is reason to believe that a beneficiary has defrauded the Medicaid program, the agency must refer the case to an appropriate law enforcement agency.\n(c) If there is reason to believe that a beneficiary has abused the Medicaid program, the agency must conduct a full investigation of the abuse.","path":["Title 42—Public Health","CHAPTER IV—CENTERS FOR MEDICARE \u0026 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"],"source_url":"https://www.ecfr.gov/api/versioner/v1/full/2026-08-25/title-42.xml","current_through":"2026-08-25","vintage":"","retrieved_at":"2026-08-27T02:26:11Z","sha256":"33b5bdd5c9a8f11e3db3f4bae91ea9901b946863b556f987f7a68724326fd49b","source_id":"us-cfr","stale":true,"prev":"us/42-cfr-455.14","next":"us/42-cfr-455.16"},"notice":"GroundRules: Original legal text. Not legal advice."}