SECTION .0700 – recipient fraud and abuse

 

10A NCAC 22F .0701        DEFINITION OF FRAUD AND ABUSE

(a)  For purposes of this Section the word

"person" includes any natural person, association, consortium,

corporation, body politic, partnership, or other group, entity or organization.

(b)  Abuse.  The type of abuse to which the Medicaid program

is extremely vulnerable is recipient overutilization of medical and health care

services for which he or she is eligible.  A recipient may be regarded as

overutilizing the program care and services if he or she has been furnished

covered items or services at a frequency or amount not medically necessary, as

determined in accordance with utilization guidelines established by the State,

and the services were furnished at the request of the recipient.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑64;

42 C.F.R. Part 431; 42 C.F.R. Part 455;

42 C.F.R. Part 456;

Eff. May 1, 1984;

Amended Eff. May 1, 1990;

Pursuant to G.S. 150B-21.3A, rule is necessary without

substantive public interest Eff. August 22, 2015.