Administrative Code

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Virginia Administrative Code
Title 12. Health
Agency 30. Department of Medical Assistance Services
Chapter 141. Family Access to Medical Insurance Security Plan

12VAC30-141-600. Recipient audit unit.

A. Pursuant to Chapter 9 (§ 32.1-310 et seq.) of Title 32.1 of the Code of Virginia, the recipient audit unit shall investigate allegations of acts of fraud or abuse, committed by persons enrolled in the FAMIS program or the parent, adult caretaker relative, guardian, legal custodian or authorized representative on behalf of a person or persons enrolled in the FAMIS program, which result in misspent funds.

B. Any FAMIS enrollee, parent, adult caretaker relative, guardian, legal custodian or authorized representative of a FAMIS enrollee who, on the behalf of others, attempts to obtain benefits to which the enrollee is not entitled by means of a willful false statement or by willful misrepresentation, or by willful concealment of any material facts, shall be liable for repayment of any excess benefits received and the appropriate interest charges.

C. Upon the determination that fraud or abuse has been committed, criminal or civil action may be initiated.

D. When determining the amount of misspent funds to be recovered, capitation fees shall be included for FAMIS enrollees who received benefits through managed care.

E. Access to FAMIS enrollees' records by authorized DMAS representatives shall be permitted upon request.

Statutory Authority

§§ 32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 19, Issue 21, eff. August 1, 2003.

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