N.J. Admin. Code § 10:69-9.15

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:69-9.15 - Eligibility fraud by applicants and beneficiaries

(a) To protect the CWA and the public, it is essential to exercise appropriate controls against the commission of fraud relating to program eligibility.

(b) A person is presumed innocent until convicted. Therefore, except as provided in (c) below, Medicaid coverage shall be continued to an eligible person, even though there is reason to suspect that fraud has been committed, while the facts are under review by the agency or the law enforcement authority.

(c) Resolution of the question of possible fraud requires the cooperation of the beneficiary to protect his or her own interest; therefore, a beneficiary's failure or refusal to cooperate in the investigation would be grounds for suspending Medicaid coverage pending resolution of the issue. If during the investigation of an application for Medicaid, substantial evidence of fraud appears, disposition of the application shall be deferred pending resolution of the issue.

(d) Statutory authority regarding the identification and prosecution of Medicaid fraud may be found in New Jersey Statutes Annotated, and includes, but is not necessarily limited to, the following:

1.2C:20-4 Theft by Deception;

2.N.J.S.A. 2C:21-1a Forgery;

3.N.J.S.A. 2C:21-3b Offering a False Instrument for Filing;

4.2C:28-2 False Swearing;

5.2C:28-3 Unsworn Falsification to Authorities;

6.2C:28-7 Tampering with Public Records or Information; and

7.30:4D-17 Penalty for Medicaid fraud

N.J. Admin. Code § 10:69-9.15

Amended by 49 N.J.R. 3729(a), effective 12/4/2017