Fraud, Waste and Abuse

Fraud, Waste and Abuse Policies and Processes | Reporting Procedures | Training | Additional Resource Links

fwa

Fraud, Waste and Abuse Policies and Processes

• Fraud, Waste and Abuse Policy
• Investigative Process
• SIU Rebuttal Process

reporting

Reporting Procedures

• Potential Fraud, Waste and Abuse Referral Form
• Provider Self-Audit and Referral Form
  • Provider Self-Audit Protocol Updated 04/27/2022
  • Attachment #1 – Carelon Claims Spreadsheet
  • Attachment #2 – Carelon Provider Self-Audit Referral Form
  • Attachment #3 – Carelon Provider Audit Response
  • Attachment #4 – Carelon Provider Self-Audit Work Plan Form
• Providers: Call 1-877-615-8503 and speak with a representative
• Members: Visit https://pa.carelon.com/members/
• Online: https://www.fighthealthcarefraud.com/
  • Select Carelon under the drop-down for “Who is the insurance company?”
• Email: BHSIU@carelon.com

Carelon SIU Department Contact Information

training

Trainings

Mandatory Annual Training

• Interactive Fraud, Waste, and Abuse Training

additional

Additional Resource Links

• Department of Health and Human Services (DHS)
• Code of Federal Regulation (TITLE 42-Public Health, Chapter IV-CMS, DHHS, SUBCHAPTER C-Medical Assistance Programs, Part 455- Program Integrity: Medicaid)
• Office of Inspector General (OIG)
• Center for Medicare and Medicaid Services (CMS)
• National Association of Medicaid Fraud Control Units (NAMFCU)
• Pennsylvania Attorney General
• Pennsylvania Bureau of Program Integrity
• Pennsylvania Code – Fraud and Abuse Sanctions (1101.77)
• Pennsylvania Code – Provider (1101.75) and Recipient (1101.92) Prohibited Acts
• Pennsylvania Code – Medicaid Provisions (Medical Assistance Provisions)