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Payment Holds
A payment hold is a temporary denial of reimbursement under the Medicaid or other HHS program for items or services furnished by the provider of interest.
This stoppage is considered an administrative sanction that stays in place until the matter in dispute between the provider and the Health and Human Services Commission is resolved.
Payment Holds Due to a Credible Allegation of Fraud (CAF)
Federal law defines a “credible allegation of fraud” as an “allegation, which has been verified by the State, from any source.” 42 CFR § 455.2 states that the source of these allegations may include, but are not limited to, “(1) fraud hotline complaints, (2) claims data mining, (3) patterns identified through provider audits, civil false claims cases, and law enforcement investigations. Allegations are considered credible when they have indicia of reliability and the State Medicaid Agency has reviewed all allegations, facts, and evidence carefully and acts judiciously on a case-by-case basis.
For more information on Payment Holds Due to a Credible Allegation of Fraud (CAF), can download the report (PDF, 24 KB, 3 pages, requires Adobe Acrobat Reader).
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