CMP.6.6.010 Fraudulent Claims/Reporting and Investigations

If the Employer, Plan Administrator or Claims Administrator/Managed Care Provider has evidence that a claim is false or fraudulent the claim shall be denied and the Plan Administrator shall report the matter to the Lac Courte Oreilles Insurance Appeal Board designated by the Lac Courte Oreilles Tribal Governing Board within 10 business days. The Lac Courte Oreilles Insurance Appeal Board may require an investigation for an allegedly false or fraudulent claim. On any investigation, the results shall be reported to the Lac Courte Oreilles Insurance Appeal Board. If based on the investigation, the Lac Courte Oreilles Insurance Appeal Board has a reasonable basis to believe that a violation of a State or Federal criminal code has occurred; the Lac Courte Oreilles Insurance Appeal Board may refer the results of the investigation to the Lac Courte Oreilles Tribal Court for final resolution.