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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 1: Provider Enrollment and Responsibilities : 1.7 Medicaid Waste, Abuse, and Fraud Policy : 1.7.5 MCO SIU Case Referrals

1.7.5
An MCO or SIU must refer a case to both HHSC-OIG and OAG-MFCU in the following situations:
When waste, abuse or fraud is discovered in the Medicaid or CHIP programs. (The MCO SIU must immediately notify the HHSC-OIG and OAG-MFCU and begin payment recovery efforts, unless HHSC-OIG or OAG-MFCU notifies the MCO to stop the recovery effort, as provided in Tx. Govt. Code §531.1131.)
When possible waste, abuse, or fraud is discovered in the Medicaid or CHIP programs. (The MCO SIU must refer the alleged fraud or abuse to HHSC-OIG within 30 working days of completing a review. The SIU report and referral must completely and accurately detail its findings in accordance with 1 TAC §353.502.)

Texas Medicaid & Healthcare Partnership
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