Referrals for investigations are received from the following:
Any leads received by DMA will be referred to the county dss in writing for investigation. The dss investigator should enter a pending referral in EPICS within seven workdays of date of the referral. If an Intentional Program Violation (IPV) or an Inadvertent Household Error (IHE) is established, update the pending status in EPICS to agree with the findings. Follow the instructions in the EPICS User's Guide.
Regardless of the results of the investigation, the county must inform the Division of Medical Assistance Program Integrity Coordinator of the status of the investigation, in writing, within 60 days from the date of the referral letter.
During their regular review, Quality Assurance staff sometimes detects possible fraud or misrepresentation. Cases found in error or suspected of fraud or misrepresentation will be referred to the county dss for further investigation. The dss investigator should enter a pending referral in EPICS within seven workdays of date of the referral.
If you receive information from other agencies, institutions, providers, other recipients or private citizens, you are required to investigate the lead. Emphasize that such reporting will be kept confidential. Some people may be reluctant to report suspected cases of fraud if they feel their names will be disclosed.
REVISED 11/01/11 - CHANGE NO. 15-11
During the application and review processes, the county dss staff may discover cases of possible fraud, abuse, or misrepresentation that need to be evaluated and/or investigated for a possible overpayment. At this point they should send a DMA-7057, Referral for Investigation, to the Program Integrity Unit. There are two types of in-house referrals. They are:
REISSUED 07/01/08 - CHANGE NO. 11-08
For questions or clarification on any of the policy contained in these manuals, please contact your local county office.