Title 42

PART 455

Part 455 - Program Integrity: Medicaid

PART 455 - PROGRAM INTEGRITY: MEDICAID Authority:42 U.S.C. 1302. Source:43 FR 45262, Sept. 29, 1978, unless otherwise noted.

42:4.0.1.1.13.0.118.1SECTION 455.1
   455.1 Basis and scope.
42:4.0.1.1.13.0.118.2SECTION 455.2
   455.2 Definitions.
42:4.0.1.1.13.0.118.3SECTION 455.3
   455.3 Other applicable regulations.
42:4.0.1.1.13.1SUBPART A
Subpart A - Medicaid Agency Fraud Detection and Investigation Program
42:4.0.1.1.13.1.118.1SECTION 455.12
   455.12 State plan requirement.
42:4.0.1.1.13.1.118.2SECTION 455.13
   455.13 Methods for identification, investigation, and referral.
42:4.0.1.1.13.1.118.3SECTION 455.14
   455.14 Preliminary investigation.
42:4.0.1.1.13.1.118.4SECTION 455.15
   455.15 Full investigation.
42:4.0.1.1.13.1.118.5SECTION 455.16
   455.16 Resolution of full investigation.
42:4.0.1.1.13.1.118.6SECTION 455.17
   455.17 Reporting requirements.
42:4.0.1.1.13.1.118.7SECTION 455.18
   455.18 Provider's statements on claims forms.
42:4.0.1.1.13.1.118.8SECTION 455.19
   455.19 Provider's statement on check.
42:4.0.1.1.13.1.118.9SECTION 455.20
   455.20 Beneficiary verification procedure.
42:4.0.1.1.13.1.118.10SECTION 455.21
   455.21 Cooperation with State Medicaid fraud control units.
42:4.0.1.1.13.1.118.11SECTION 455.23
   455.23 Suspension of payments in cases of fraud.
42:4.0.1.1.13.2SUBPART B
Subpart B - Disclosure of Information by Providers and Fiscal Agents
42:4.0.1.1.13.2.118.1SECTION 455.100
   455.100 Purpose.
42:4.0.1.1.13.2.118.2SECTION 455.101
   455.101 Definitions.
42:4.0.1.1.13.2.118.3SECTION 455.102
   455.102 Determination of ownership or control percentages.
42:4.0.1.1.13.2.118.4SECTION 455.103
   455.103 State plan requirement.
42:4.0.1.1.13.2.118.5SECTION 455.104
   455.104 Disclosure by Medicaid providers and fiscal agents: Information on ownership and control.
42:4.0.1.1.13.2.118.6SECTION 455.105
   455.105 Disclosure by providers: Information related to business transactions.
42:4.0.1.1.13.2.118.7SECTION 455.106
   455.106 Disclosure by providers: Information on persons convicted of crimes.
42:4.0.1.1.13.2.118.8SECTION 455.107
   455.107 Disclosure of affiliations.
42:4.0.1.1.13.3SUBPART C
Subpart C - Medicaid Integrity Program
42:4.0.1.1.13.3.118.1SECTION 455.200
   455.200 Basis and scope.
42:4.0.1.1.13.3.118.2SECTION 455.202
   455.202 Limitation on contractor liability.
42:4.0.1.1.13.3.118.3SECTION 455.230
   455.230 Eligibility requirements.
42:4.0.1.1.13.3.118.4SECTION 455.232
   455.232 Medicaid integrity audit program contractor functions.
42:4.0.1.1.13.3.118.5SECTION 455.234
   455.234 Awarding of a contract.
42:4.0.1.1.13.3.118.6SECTION 455.236
   455.236 Renewal of a contract.
42:4.0.1.1.13.3.118.7SECTION 455.238
   455.238 Conflict of interest.
42:4.0.1.1.13.3.118.8SECTION 455.240
   455.240 Conflict of interest resolution.
42:4.0.1.1.13.4SUBPART D
Subpart D - Independent Certified Audit of State Disproportionate Share Hospital Payment Adjustments
42:4.0.1.1.13.4.118.1SECTION 455.300
   455.300 Purpose.
42:4.0.1.1.13.4.118.2SECTION 455.301
   455.301 Definitions.
42:4.0.1.1.13.4.118.3SECTION 455.304
   455.304 Condition for Federal financial participation (FFP).
42:4.0.1.1.13.5SUBPART E
Subpart E - Provider Screening and Enrollment
42:4.0.1.1.13.5.118.1SECTION 455.400
   455.400 Purpose.
42:4.0.1.1.13.5.118.2SECTION 455.405
   455.405 State plan requirements.
42:4.0.1.1.13.5.118.3SECTION 455.410
   455.410 Enrollment and screening of providers.
42:4.0.1.1.13.5.118.4SECTION 455.412
   455.412 Verification of provider licenses.
42:4.0.1.1.13.5.118.5SECTION 455.414
   455.414 Revalidation of enrollment.
42:4.0.1.1.13.5.118.6SECTION 455.416
   455.416 Termination or denial of enrollment.
42:4.0.1.1.13.5.118.7SECTION 455.420
   455.420 Reactivation of provider enrollment.
42:4.0.1.1.13.5.118.8SECTION 455.422
   455.422 Appeal rights.
42:4.0.1.1.13.5.118.9SECTION 455.432
   455.432 Site visits.
42:4.0.1.1.13.5.118.10SECTION 455.434
   455.434 Criminal background checks.
42:4.0.1.1.13.5.118.11SECTION 455.436
   455.436 Federal database checks.
42:4.0.1.1.13.5.118.12SECTION 455.440
   455.440 National Provider Identifier.
42:4.0.1.1.13.5.118.13SECTION 455.450
   455.450 Screening levels for Medicaid providers.
42:4.0.1.1.13.5.118.14SECTION 455.452
   455.452 Other State screening methods.
42:4.0.1.1.13.5.118.15SECTION 455.460
   455.460 Application fee.
42:4.0.1.1.13.5.118.16SECTION 455.470
   455.470 Temporary moratoria.
42:4.0.1.1.13.6SUBPART F
Subpart F - Medicaid Recovery Audit Contractors Program
42:4.0.1.1.13.6.118.1SECTION 455.500
   455.500 Purpose.
42:4.0.1.1.13.6.118.2SECTION 455.502
   455.502 Establishment of program.
42:4.0.1.1.13.6.118.3SECTION 455.504
   455.504 Definitions.
42:4.0.1.1.13.6.118.4SECTION 455.506
   455.506 Activities to be conducted by Medicaid RACs and States.
42:4.0.1.1.13.6.118.5SECTION 455.508
   455.508 Eligibility requirements for Medicaid RACs.
42:4.0.1.1.13.6.118.6SECTION 455.510
   455.510 Payments to RACs.
42:4.0.1.1.13.6.118.7SECTION 455.512
   455.512 Medicaid RAC provider appeals.
42:4.0.1.1.13.6.118.8SECTION 455.514
   455.514 Federal share of State expense of the Medicaid RAC program.
42:4.0.1.1.13.6.118.9SECTION 455.516
   455.516 Exceptions from Medicaid RAC programs.
42:4.0.1.1.13.6.118.10SECTION 455.518
   455.518 Applicability to the territories.