CMS Pub. 100-16, ch. 21, § 50.7.5

42 C.F.R. §§ 422.503(b)(4)(vi)(G), 423.504(b)(4)(vi)(G)

Each sponsor referral to the NBI MEDIC should contain specifics that will allow an

investigator to follow-up on a case including basic identifying information and contacts

as well as a description of the allegations.

If available, a referral should include:

• Name of:

o compliance officer or SIU investigator, and

o Organization;

• Contact information for follow up;

• Summary of the Issue:

o Include the basic who, what, when, where, how, and why; and

o Any potential legal violations;

• Specific Statutes and Allegations:

o List civil, criminal, and administrative code or rule violations, state and

federal; and

o Provide detailed description of the allegations or pattern of fraud, waste,

or abuse;

• Incidents and Issues:

o List incidents and issues related to the allegations;

• Background information:

o Contact information for the complainant, the perpetrator or subject of the

investigation, and beneficiaries, pharmacies, providers, or other entities

involved; and

o Additional background information that may assist investigators, such as

names and contact information of informants, relators, witnesses,

websites, geographic locations, corporate relationships, networks;

• Perspectives of Interested Parties:

o Perspective of Plan, CMS, enrollee;

• Data:

o Existing and potential data sources;

o Graphs and trending;

o Maps; and

o Financial impact estimates; and

• Recommendations in Pursuing the Case:

o Next steps, special considerations, cautions.

Call the NBI MEDIC at 1-877-7SafeRX (1-877-772-3379).

For referral forms, go to:

http://www.healthintegrity.org/html/contracts/medic/case_referral.html

The NBI MEDIC may request additional information in order to fully investigate and

resolve the matter. The sponsor shall furnish additionally requested information within

30 days, unless the NBI MEDIC specifies otherwise. In instances where the MEDIC

requires information in less than 30 days, all parties involved will be notified as soon as

possible. Sponsors should provide updates to the NBI MEDIC when new information

regarding the matter is identified.