42 CFR Part 455 Subpart D — Medicaid Program Integrity: MCO Special Investigation Units

Source: Centers for Medicare & Medicaid Services · Document date: 2016-05-06 · Type: regulation

Federal regulation (42 CFR 455.236) requiring Medicaid managed care organizations to establish and maintain Special Investigation Units for detecting and preventing fraud, waste, and abuse. Establishes organizational, reporting, and referral requirements for MCO SIUs. Does not specify a minimum staffing ratio — the 1:10,000 benchmark comes from the CMS Toolkit (see doc-058), not from this regulation.

Significance: Legal basis for the MCO SIU requirement. The absence of a staffing ratio mandate in the regulation is why Minnesota's contracts also lack minimum staffing requirements.

Tags: regulation, 42-CFR-455, SIU, MCO, CMS, fraud-detection