Provider Handleiding


The Department of Human Services (DHS) has mandated minimum requirements for Medical Assistance to ensure that Carelon and Carelon providers are preventing and detecting potential fraud, waste and abuse. 

  • Fraude: Elke vorm van opzettelijke misleiding of verkeerde voorstelling van zaken, gedaan met de wetenschap dat de misleiding zou kunnen leiden tot enig ongeautoriseerd voordeel voor de persoon die het begaat – of een andere persoon. De poging zelf is fraude, ongeacht of deze al dan niet succesvol is
  • Verspilling: omvat overmatig gebruik van services of andere praktijken die direct of indirect leiden tot onnodige kosten. Verspilling wordt over het algemeen niet geacht te worden veroorzaakt door opzettelijke acties, maar vindt plaats wanneer hulpbronnen worden misbruikt.
  • Misbruik: Wanneer zorgverleners of leveranciers zich niet aan goede medische praktijken houden met als gevolg onnodige of buitensporige kosten, onjuiste betaling, misbruik van codes of diensten die medisch niet noodzakelijk zijn.

In the Pennsylvania HealthChoices Behavioral Health Program Standards and Requirements, Appendix F obliges Carelon and Carelon providers to comply with Federal and State regulations and implement compliance programs and efforts that prevent and detect fraud, waste, and abuse. Subsequently, Carelon has implemented a compliance and program integrity plan with policies and procedures, trainings, and reporting responsibilities. The complete documentation for Carelon requirements are outlined on the Carelon Fraud and Abuse webpage available at the following address:


The Special Investigations Unit (“SIU”) investigates suspected incidents of FWA for all types of services. Carelon may take corrective action with a Provider or Facility, which may include, but is not limited to:

  • Written warning and/or education: Carelon sends letters to the Provider or Facility advising the Provider or Facility of the issues and the need for improvement. Letters may include education or requests for repayment, or may advise of further action.
  • Medical record review: Carelon reviews medical records to investigate allegations or validate the appropriateness of Claims submissions.
  • Edits: A certified professional coder or investigator evaluates Claims and places payment or system edits in Carelon’s Claims processing system. This type of review prevents automatic Claims payments in specific situations.
  • Recoveries: Carelon recovers overpayments directly from the Provider or Facility. Failure of the Provider or Facility to return the overpayment may result in reduced payment for future Claims, termination from our network, or legal action.

Beleid en procedures

Carelon has established policies and procedures to meet the DHS requirements specific to the prevention and detection of fraud, waste, and abuse (FWA). All Carelon providers are responsible to meet the requirements on the Carelon Fraud and Abuse webpage. Carelon will announce updates to or revisions to the Carelon Fraud and Abuse webpage in the Compliance Alert Section of Waarde toegevoegd, Carelon’s monthly provider newsletter.

Verplichte trainingen

All providers are required to have at least one representative attend an Annual Fraud and Abuse Training offered by Carelon. The provider or provider representative is responsible for reporting all information at the training to the provider and/or the entire staff of the provider agency. If a provider is unable to attend the Fraud and Abuse Training, the provider is responsible to independently review the mandatory training and document when the training is completed within their records. Check the Webpagina Provider Trainings voor fraude- en misbruiktrainingsdata.

All new providers are responsible to complete and review the documentation and previous trainings available on the Carelon Fraude en misbruik webpagina. Alle nieuwe providers moeten elk kwartaal een van de trainingswebinars voor fraude en misbruik van nieuwe providers bijwonen. Controleer de Webpagina Provider Trainings voor beschikbare data.


Alle aanbieders zijn verplicht vermoedens van fraude en misbruik te melden. Als iemand vermoedt dat een Lid of Aanbieder (een persoon die voordelen ontvangt) fraude, verspilling of misbruik heeft gepleegd, hebben ze het recht om dit te melden. Geen enkele persoon die schendingen of vermoede fraude en misbruik meldt, zal worden vergolden om dit te doen. De naam van de persoon die het incident meldt en zijn of haar terugbelnummer worden strikt vertrouwelijk gehouden door onderzoekers.

Meld zorgen door:

  • op bezoek At the top of the page click “Report it” and complete the “Report Waste, Fraud and Abuse” form. For the “Who is the insurance company?” dropdown, select “Carelon”
  • Providerservices bellen

Any incident of fraud, waste or abuse may be reported to Carelon anonymously; however, Carelon’s ability to investigate an anonymously reported matter may be limited if Carelon doesn’t have enough information. Carelon encourages Providers and Facilities to give as much information as possible. Carelon appreciates referrals for suspected fraud, but be advised that Carelon does not routinely update individuals who make referrals as it may potentially compromise an investigation. Learn more at

The Department of Human Services has established a hotline to report suspected fraud, waste, and abuse committed by any entity providing services to Medical Assistance recipients. The hotline number is 1-866-DHS-TIPS (1-844-347-8477) and is available between the hours of 8:30 AM and 3:30 PM, Monday through Friday. Voice mail is available at all other times. Callers do not have to give their name and may call after hours and leave a voice mail if they prefer.

Some common examples of fraud, waste and abuse are:

  • Het factureren of in rekening brengen van ontvangers van medische hulp voor gedekte diensten
  • Meerdere keren factureren voor dezelfde service
  • Afgifte van generieke geneesmiddelen en facturering voor merkgeneesmiddelen
  • Falsifying records
  • Ongepaste of onnodige services uitvoeren

Suspected fraud, waste and abuse may also be reported via the website at:—General-Information.aspx

You do not have to give your name if you use the website or email to report fraud, waste or abuse. The website contains additional information on reporting fraud, waste and abuse