Medicaid Fraud and Abuse Confidential Complaint

You are encouraged to report matters involving Medicaid fraud and program abuse. If you want to report fraud or program abuse, you may remain anonymous. All complaints of misconduct are kept confidential and are protected from disclosure according to the North Carolina State Administrative Procedure Act, Section 10A NCAC 23H .0103 (formerly 10A NCAC 21A.0403) or Section 10A NCAC 22F.0106. The Division of Health Benefits (DHB) Office of Compliance and Program Integrity will not reveal the identity of the complainant to any person, except as required by law.

After completion of form, you must press the SUBMIT button. You will receive an acknowledgement email to print for your record.

Indicates required field

Do you wish to remain anonymous?

If you wish to remain anonymous, you do not have to provide your personal information. Failure to provide detailed information can affect Program Integrity’s ability to review the complaint to its fullest extent.

First Name

Middle Name

Last Name

Suffix

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

County

Daytime Telephone

Evening Telephone

Other Telephone

Who is this complaint against?

Beneficiary Name

First Name

Middle Name

Last Name

Suffix

Other names used/known as

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

County

Date of Birth

Check the Type of Medicaid Fraud, Waste or Abuse

Please provide as much detail as possible including names of individuals involved, employer name, self-employment business name, dates of alleged occurrence and details of the complaint. Failure to provide detailed information can affect the ability to review the complaint to its fullest extent.

Is income from employment or self-employment

Who is employed or self-employed?

Name of Employer or Self-Employment Business Name

Employer's Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Employer's Phone Number

Child Support/Alimony

Who is providing income?

Is it court ordered or paid directly to beneficiary?

Amount

How often is income received?

Contributions from family

Name of individuals providing income

Address and/or telephone of individuals

Amount

Other income not listed

List the income type

Individual or company providing income

Contact information for individual or company

Names of household members not reported and relationship to beneficiary

Type of asset/resource

Value or amount of asset/resource of property

Name of bank or financial institution

Name of life insurance company

County or State asset/resource is located

Name of individual who provides (pays for) the insurance

Name of insurance

Policy number of insurance, if known

Is insurance coverage court ordered?

If a copy of the insurance card is available, please fax front and back to (919) 800-3186.

Is the card being used with the beneficiary's knowledge?

Name of the individual using card for services

Was the card used once or has it been multiple times?

Name of medical provider the card was used to receive services

Dates of alleged occurence

Dates of alleged occurence
	Dates of alleged occurence	Item weight

more items

Type of service that was received

New address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Approximate month of move

Enter month and year (i.e. 06/2021)

Please provide as much detail as possible including names of individuals involved, dates of alleged occurrence and details of the complaint. Failure to provide detailed information can affect the ability to review the complaint to its fullest extent.

Is your complaint about

Provider NPI Number

Provider Name

Provider Address

Provider Address 2

Provider City/Town

Provider State/Province

Provider ZIP/Postal Code

Provider County

Have you filed this complaint with any other agency, insurance company, or person(s)?

Agency Name

Agency Contact Phone

Check the Type of Medicaid Fraud, Waste or Abuse

Description of allegation

Managed Care Organization

Check the Type of Medicaid Fraud, Waste or Abuse

Description of Allegation

If you have supporting documents you would like to have included in the investigation, fax or mail the documents to:

DHB Office of Compliance and Program Integrity
2501 Mail Service Center
Raleigh, NC 27699-2501

Phone: 919-527-7700
Fax: 919-831-1808

Medicaid Fraud and Abuse Confidential Complaint

Contact Information

Beneficiary

Medicaid beneficiary failed to report all income when applying for Medicaid

Medicaid beneficiary failed to report all household members

Medicaid failed to report assets/resources or property (examples cash on hand, bank accounts, life insurance, property out of country of state, etc.)

Medicaid beneficiary failed to report other insurance when applying for medical assistance

Non-Beneficiary uses a beneficiary's Medicaid card

Medicaid beneficiary is no longer living in NC but has NC Medicaid benefits

Other allegations not listed above

Provider

Managed Care Organization