N.J. Admin. Code § 10:69-9.20

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

Section 10:69-9.20 - Recovery of incorrectly paid Medicaid benefits

(a) In every fraud case, in addition to any criminal prosecution, recovery of the amount of assistance provided for medical care or supplies shall be sought. If the beneficiary is involved in a Medicaid managed care plan, the higher of the payments made by the managed care plan, or the amount expended by the Medicaid program for capitation costs shall be recovered. Recoveries of incorrect assistance by the CWAs shall be governed by N.J.A.C. 10:49-14.4(b). Recovery of civil penalties shall be pursued by DMAHS in accordance with N.J.S.A. 30:4D-17(c). The threat of prosecution should not be used as a means of effecting recovery; nor should the fact of a recovery affect the CWA decision concerning proper referral to the prosecutor. However, any recovery, or plan for recovery, should be reported to the prosecutor whenever such a referral has been made.

(b) The provision of (a) above is not intended to limit the responsibility and obligation of the CWA to seek recovery, through voluntary agreement or civil action, of funds improperly received by a client under circumstances other than fraud.

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