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Potential Fraud Referrals

If the CERT Documentation Contractor (CDC) is unable to make contact with a provider after a series of repeated attempts, including additional commercial record searches, the Problem Resolution Office will write a Potential Fraud Referral Report and send it to the appropriate Benefit Integrity office for possible action.

A few examples of reasons that would trigger the Potential Fraud Referral Report include (but are not limited to):

  1. No phone number available.
  2. Phone listing disconnected.
  3. Phone is never answered.
  4. Phone is a mobile number.
  5. State records disclose no record of business activity.
  6. Claims submitted for decedent beneficiaries.
  7. Provider is out of business with no forwarding address or phone number.

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