Involuntary Disenrollment for Fraud, Waste and Abuse
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This policy governs when Care Continuum (Network Health entities) may request cancellation or involuntary disenrollment of a member for knowingly providing fraudulent enrollment information or permitting misuse of membership privileges; it applies to members of the managed care/MA plan and to related third-party administrators acting on the plan's behalf.
No material clinical or coverage changes in this revision.
Disenrollment Criteria and Procedures
Disenrollment criteria and procedures
Covered when ALL of the following are met:
ALL of the following
Disqualifying member conduct (ONE or more):
- Member knowingly provides fraudulent information on the election/enrollment form or by another election mechanism that materially affects eligibility.
- Member intentionally permits others to use his/her enrollment card to obtain services or supplies from the plan or any authorized plan provider.
Notice and response process:
- Plan sends an advance written notice (H5215_X40) to the member that: (a) explains the reasons for the decision to involuntarily disenroll for fraudulent activity; (b) provides the effective date of termination; and (c) explains the member's right to a hearing under the plan's grievance procedures (Appeal & Grievance procedures enclosed).
- Member has 45 days from the date of the advance notice to respond or appeal.
- If no response is received, the plan mails a second and final notice (H5214_X44) indicating the plan has submitted a request to CMS to dis-enroll the member.
- All notices must be mailed to the member before submission of the disenrollment transaction to CMS.
Effect and reporting:
- Any disenrollment processed under these provisions results in a change of election to Original Medicare.
- Disenrollment is effective the first day of the calendar month after the month in which the plan provides the member the final written notice of involuntary disenrollment for fraudulent activities.
- The plan immediately notifies the CMS Regional Office so the Office of the Inspector General (OIG) may initiate an investigation of the alleged fraud and/or abuse.
Required Member Notices / Codes
| H5215_X40 | Advance notice of dis-enrollment for fraud and abuse |
| H5214_X44 | Final dis-enroll fraud notice |
| H5215_X40 | Advance notice of dis-enrollment for fraud and abuse |
| H5214_X44 | Final dis-enroll fraud notice |
Notifications and Disenrollment Submission
Notify CMS, mail H5215_X40 and H5214_X44 before submitting disenrollment
When involuntary disenrollment for fraud is pursued, the plan must notify CMS Regional Office so the OIG may investigate and process the member’s change of election to Original Medicare. All required notices (advance H5215_X40 and final H5214_X44) must be mailed to the member before the disenrollment transaction is submitted to CMS.
- Send H5215_X40 (advance notice) detailing reasons, effective date, and right to a hearing; include Appeal & Grievance procedures.
- Allow 45 days from the advance notice for the member to respond or appeal; if no response, send H5214_X44 (final notice) indicating submission to CMS.
- Mail all notices to the member prior to submitting the disenrollment transaction to CMS.
- Notify the CMS Regional Office so the OIG may initiate an investigation; disenrollment results in a change of election to Original Medicare.
Terminology
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