10- 144 C.M.R. ch. 332, § 1-3

Current through 2024-51, December 18, 2024

Section 144-332-1-3 - REFERRALS

Under certain circumstances referral to other Offices and Divisions within the Department of Health and Human Services are to be made. These include the Office of Child and Family Services (OCFS), the Office of Aging and Disability Services (OADS) and the Division of Fraud Investigation and Recovery Unit (FIRU) within OFI.

Section 3.1: Referrals to Child and Adult Protective Services

In compliance with Federal and State statutes, when information is brought to the attention of a staff member or there is reasonable cause to suspect abuse, neglect or exploitation, an immediate referral will be made to the Child or Adult Protective Unit which will investigate the suspected abuse.

Section 3.2: Referral to the Fraud Investigation and Recovery Unit (FIR) from the Eligibility Unit

If it appears that a recipient has purposely misrepresented actual circumstances (such as living arrangement, income, or assets) in order to receive MaineCare, and the individual would not have been eligible had the proper information been available at the time of application, re-determination of eligibility, or within ten days of the change in circumstances, a referral to the Fraud Investigation Unit will be made.

The report will include:

I. a detailed explanation of the misrepresentation and the effect it had on eligibility.

II. a claims history indicating the services that should not have been paid.

Section 3.3: Referrals to the Fraud Investigation and Recovery Unit (FIR) from an outside source

Complaints received directly by the Fraud Investigation and Recovery Unit may be referred to the Attorney General's Office if it is determined that:

I. the individual was enrolled in MaineCare at the time alleged fraud occurred;

II. it appears that the individual has purposely misrepresented actual circumstances to receive MaineCare;

III. the individual would not have remained eligible if the complaint is valid; and

IV. MaineCare paid for services during the time period in question.

The name of individuals supplying information who wish to remain anonymous will not be kept in the case record.

10- 144 C.M.R. ch. 332, § 1-3