New Process to Identify Claim Fraud

Effective April 29, 2018, DHHS will implement a new process to identify suspicious claims and patterns of activity in order to prevent fraud, waste, and abuse in NCTracks for Medicaid and North Carolina Health Choice, pursuant to NC Legislative Mandate Section 11H.15.(a).         

The processing of provider claims will now include an enhanced evaluation of the beneficiary's date of death, incarceration and state residency statuses. The enhanced process will utilize a combination of automated and manual processes to determine the validity of any suspected fraud, waste or abuse prior to the issuance of any payment to the provider for the claims. Additional beneficiary profile elements may be added to the evaluation over time. If inconsistencies are found, claims will pend for a review period of 20 days. Providers will receive an EOB identifying pended claims flagged for review as "CLAIM PENDED FOR BENEFICIARY STATUS REVIEW."

NCTracks will provide a daily report to county departments of social services to identify the beneficiary and the issue that triggered the review. County staff will investigate the report and update NCFAST and NCTracks, as needed. At the end of the 20-day review period, the claim will be adjudicated based on any updates to the recipient's eligibility record. At times, validation of the beneficiary's status may take longer than the 20 days allotted. Improper payment determinations made after the claim has been adjudicated will be handled by the Office of Compliance and Program Integrity and follow standard investigative/recoupment procedures. No action is required by providers.