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  • Oifp 1 Claim Fraud Referral Form

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/ / NOTIFICATION PART I INSURANCE CO.: ADDRESS: DATE REPORTED: NAIC COMPANY #: D.O.L.: POLICY#: CLAIM #: (if available) SIU #: (if available) TELEPHONE #: CONTACT PERSON: E-MAIL ADDRESS: TYPE OF COVERAGE (check appropriate box) Health (Indemnity) Health (Medicaid) Health (HMO) Dental OTHER INSURED SUBJECT PROVIDER STATUS (indicate as appropriate) PENDING PAID - IN FULL DENIED PAID - IN PART AMT. PAID: $ DATE / RANGE PD.: IF PENDING OR DENIED, EITHER IN FULL OR IN PART, THE DOLLAR AMOUNT.

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State of New Jersey. It's illegal to participate in a scheme to offer or receive kickbacks in connection with the furnishing of items or services which are billable to the Medicaid program. It's illegal to over bill Medicaid for services provided. It's illegal to receive more Medicaid benefits than you're entitled to.

Report Medicaid Beneficiary Fraud Here To report fraud by a patient who is enrolled in the Medicaid program, contact the Office of the State Comptroller, Medicaid Fraud Division (MFD) or call the MFD Hotline: 888-937-2835.

Report Through Our TipLine To call in specific information about individuals or entities who may be committing Medicaid or insurance fraud use our toll free number, 1-877-55-FRAUD (1-877-553-7283).

Medicaid Fraud It's illegal to receive more Medicaid benefits than you're entitled to. These are violations of N.J.S.A. 30:4D-17. Punishable by up to 3 years in prison and a $10,000 penalty.

Penalties and Fines Most instances of insurance fraud are third-degree crimes in New Jersey. Those convicted can face up to 5 years in prison and fines of up to $15,000. Those who commit five or more acts of Insurance Fraud with a total aggregate value of more than $1,000 can be charged with a second-degree crime.

Reporting Medicare fraud & abuse If you experience:Contact:Provider fraud or abuse in Original Medicare (including a fraudulent claim, or a claim from a provider you didn't get care from)1-800-MEDICARE (1-800-633-4227) or The U.S. Department of Health & Human Services – Office of the Inspector General1 more row

To report fraud by a patient who is enrolled in the Medicaid program, contact the Office of the State Comptroller, Medicaid Fraud Division (MFD) or call the MFD Hotline: 888-937-2835.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232