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Suspect possible fraud when the following key factors exist:
The customer or representative presents a fraudulent (misleading) representation as a statement of fact;
The customer or representative knows or believes that the misleading representation or omission of facts is untrue or makes the misrepresentation or omission with reckless disregard of the truth;
The customer or representative misrepresents or omits facts for the purpose of influencing eligibility-related decisions, provision of benefits, or claims processing payment decisions.
The fact misrepresented is significant in determining the customer’s eligibility. An incorrect age, for example, is not evidence of possible fraud unless age is an eligibility factor. Willful failure to report facts that would result in ineligibility includes, but is not limited to, the following:
Omission of property ownership, real or personal, which is in excess of the ALTCS resource limit;
Understated or omitted income which, when considered, makes the customer ineligible for the AHCCCS Service Package he or she is receiving, or raises the amount the customer must pay toward medical expenses (premiums or ALTCS Share-of-Cost).