Medi-Cal Fraud Referrals

The local Special Investigation Unit (SIU) does not process Fraud referrals for MC only cases. Per Common Place handbook chapter 38, MC only fraud referrals should be sent to DHCS Investigations Branch in Sacramento.

The EW has the option to require a client to complete a face-to-face interview before benefits are redetermined ONLY when there is suspicion of fraud. A face-to-face interview is not required as long as any questions or discrepancies can be resolved using one or more steps of the ex parte process, a follow-up telephone contact and/or by mail using the MC 355.


At least one of the following circumstances must apply for the EW to require a client to attend a face-to-face interview:

  • There is questionable information on the MC forms provided by the client.
  • There is questionable information on the verifications provided by the client.


When a face-to-face interview is conducted, the EW must document the reason in the Journal Detail page for program review and audit purposes.

Medi-Cal Fraud Referrals Procedures

The following describes the steps and actions to be taken by an EW when completing a fraud referral:

  1. Search for the “Confidential Medi-Cal Complaint Form” (MC 609) DEBS Forms Library.
  2. On the MC 609:
  • Complete the “For County Staff Only” section.
  • Do not complete any section that says “For DHS Staff Only”.
  1. Attach any supporting documents and either e-mail or fax along with the MC 609 to the DHCS Investigations Branch: E-Mail: fraud@dhcs.ca.gov Fax: (916) 327-4293
  2. Document on the Journal page that a MC fraud referral was initiated.
  3. Submit a copy of the referral to Imaging for scanning following the District Office business process.
  4. Upon receipt of the investigator’s report, the EW will make changes as needed and process the case/application appropriately. 

The following describes the steps and actions taken by the DHCS investigator when a fraud referral is received:

  1. Conducts an investigation to gather facts that prove or disprove the allegations.
  2. Informs the EW via telephone call (within 10 days) of the results of their investigation.
  3. Sends the EW (within three days of the telephone call) the investigator’s report with all information which supports his/her findings.
  4. Attaches a “FRED Eligibility Action Report” to the investigator’s report for completion by the EW.

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