Members Do You Suspect Fraud?

Do You Suspect Fraud?

You can help CenCal Health stop fraud, waste, and abuse. Report your concerns to CenCal Health anytime you feel fraud, waste or abuse might be occurring with the health care and/or health care services you are receiving or have witnessed others receiving.

Healthcare Fraud, Waste and Abuse are defined as:

Fraud

An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law (Title 42 CR 455.2; Welfare and Institutions Code 1403.1(i))

Waste

Over utilization of services (not caused by criminally negligent actions) and the misuse of resources.

Abuse

Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program or in reimbursement for services that are not Medically Necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid program. (Title 42 CFR 455.2 and as further defined in Welfare and Institutions Code 14043.1(a)).

REPORTING WILL ALWAYS REMAIN CONFIDENTIAL.

How To Report: 
  • Call our toll free 24-hour hotline at (866) 775-3944, or
  • Fill out a Fraud, Waste and Abuse Form

Fraud, Waste and Abuse (FWA) Forms:

FWA by a Member (English Form) (Spanish Form)

FWA by a Provider (English Form) (Spanish Form)

When Reporting Fraud, Waste or Abuse please provide as much of the following information as possible:

  • Name of person or persons suspected of committing fraud, waste or abuse. (First name, Last Name).
  • Identifying information such as: Provider/Member name, address or telephone number.
  • Description and Details of the suspected fraud waste or abuse: who, what, where, when, date and time of incident or incidents.
  • Any documentation you may have which is related to the situation.
  • Your name, telephone number (if you would like to be contacted), and address.
  • Please always note the program this issue is about.

Mail your completed FWA Form to the following address:

CenCal Health
Attn: Fraud Investigations-Compliance
4050 Calle Real
Santa Barbara, CA 93110

If your concern is not related to fraud, waste or abuse, please call CenCal Health at (877) 814-1861. You can discuss your concern with a Member Services Representative. Or, if you cannot hear or speak well, please call California Relay at 711 or TTY: 1-833-556-2560. You can also submit a complaint online”.