A person engaged in the business of insurance having knowledge or a reasonable belief that a fraudulent insurance act has been, is being, or will be committed shall provide information concerning the known or suspected fraudulent insurance act to the commissioner in writing within sixty days of having that knowledge or reasonable belief. The information may be reported on the national association of insurance commissioners uniform suspected insurance fraud reporting form, a copy of which is attached as appendix A. Thereafter, the person engaged in the business of insurance shall promptly provide to the commissioner any additional information that the commissioner may request concerning the known or suspected fraudulent insurance act. For the purposes of this rule, a reasonable belief means that the person engaged in the business of insurance has a given fact or combination of facts which in their totality result in a determination that more likely than not, a fraudulent insurance act has been, is being, or will be committed.

History: Effective March 1, 2004; amended effective April 1, 2017.

General Authority: NDCC 28-32-02

Law Implemented: NDCC 26.1-02.1, 26.1-02.1-11

Appendix A

UNIFORM SUSPECTED INSURANCE FRAUD REPORTING FORM

State of Division of Insurance Fraud Bureau

For State Use Only Case No. State: FYI

Reporting Person:		Insurance Company:		NAIC#
Mailing address:		Phone number: ( ) Fax number: ( ) E-mail address:
Detailed synopsis: Attach additional pages, if necessary.
Date of Loss / Injury: Address of Loss / Injury: (City) (State) (Zip)		Dates of Service: to Description of Service:
Claim #		Policy #
Reserve Amount $	Amount Paid $	Date Paid	Procedure Code #'s: ☐ CPT ☐ CDT	Insurance Type ☐ PC ☐ WC ☐ HC ☐ Auto ☐ Life ☐ Disability
Loss Amount $	Settlement Amt. $	Date Paid	Civil Litigation Pending: ☐ Yes ☐ No

Subject Information

Type:	Name (Last / Business):	(First):	(Middle):	Date of birth:	Age:	SSN:
Street Address (include P.O. Box and apartment #'s):			Address Type: ☐ Res. ☐ Bus. ☐ Maildrop ☐ Other	Fed. TIN ☐ EIN ☐ Number:	Sex: M ☐ F ☐
City:	State:	Zip:	County:	Telephone No.: ( )	Phone Type: ☐ home ☐ cell ☐ bus
Driver's License #:	State:	VIN:		Telephone No.: ( )	Phone Type: ☐ home ☐ cell ☐ bus
Vehicle Year:	Make:	Model:	License Plate #:	Reported Injuries:
Employer:	Address & Phone #:			Occupation:
Additional Party Involved ☐ AKA Information: ☐ See Additional Party Involved/AKA Information			Comments:

Case Details (check all that apply)

SIU Investigation Completed ☐ Yes ☐ No		Date Completed:
Is there any reason to believe that this incident is related to other suspected fraudulent activity? ☐ Yes ☐ No
☐ Statements (Witness / Insured / Subject) ☐ Sworn ☐ Recorded ☐ Proof of Loss ☐ Continuance of Disability Forms ☐ Medical Records ☐ Other	☐ EUO / Deposition ☐ Copies of Receipts ☐ Expert Reports ☐ Videos / Photos ☐ Claim Information ☐ Other	☐ Law Enforcement / Other Agency Reports ☐ Claim History Extracts ☐ IME Reports ☐ Investigative Reports ☐ External Database results ☐ Other

Identify Other Agency You Have Contacted Regarding This Referral

Agency Type: ☐ Other State Fraud Bureau ☐ Law Enforcement ☐ Other Insurance Company ☐ Regulatory Agency ☐ Other
Agency: _ (Address) Telephone ( ) __	Contact Person: _ (City) (State) (Zip) _ Fax ( ) Case/Claim No.

Suspected Fraud Types (check all that apply)

1. ☐ Arson
2. ☐ home ☐ vehicle ☐ business
3. ☐ Fictitious loss ☐ damages ☐
4. ☐ Fictitious theft
5. ☐ vehicle ☐ property
6. ☐ Inflated inventory
7. ☐ Inflated loss ☐ damages ☐
8. ☐ Inflated theft
9. ☐ vehicle ☐ property
10. ☐ Double-dipping
11. ☐ Exaggerated injuries
12. ☐ Injuries not related to work
13. ☐ Malingerers
14. ☐ Misappropriated vehicle salvage
15. ☐ Premium avoidance
16. ☐ Prior injuries
17. ☐ Slip and fall
18. ☐ Staged injury / accident at work
19. ☐ Staged collisions
20. ☐ Paper accidents
21. ☐ Other _____
22. ☐ Agent fraud
23. ☐ Application fraud
24. ☐ Billing for services/products not provided
25. ☐ Failure to disclose multiple insurance companies
26. ☐ False claims
27. ☐ Illegal solicitation (cappers)
28. ☐ Issued fraudulent insurance policies, certificates, binders, ID cards
29. ☐ Misrepresentation of services / products provided
30. ☐ Kickbacks/bribery
31. ☐ Money laundering
32. ☐ Multiple claims
33. ☐ Possession/sold fraudulent insurance policies, certificates, binders, ID cards
34. ☐ Questioned documents
35. ☐ altered ☐ forged ☐ falsified
36. ☐ duplicated
37. ☐ Received compensation for referral to health care provider or attorney
38. ☐ Ring / organized activity type
39. ☐ Duplicate billing for same service
40. ☐ Forged prescriptions
41. ☐ Fraudulent death claims
42. ☐ Over-utilization of services
43. ☐ Prescription abuse / doctor shopping
44. ☐ Prescriptions issued for non-medical purposes
45. ☐ Unbundling
46. ☐ Upcoding
47. ☐ Misrepresented non-covered services as covered
48. ☐ Changing dates of service, CPT/CD/Diagnostic codes
49. ☐ Charges inconsistent with services provided
50. ☐ Products billed are inconsistent with the products
51. ☐ Using unqualified/unlicensed persons to perform billable services
52. ☐ Other

Subject / Additional Party Types

CL	Chairman	PH	Pharmacist	TPA	Third Party Administrator
IN	Insured	CHI	Chiropractor	FP	False Provider
WT	Witness	NP	Nurse Practitioner	UP	Unlicensed Provider
LC	Lawyer for Claimant	LPN	Licensed Practical Nurse	MN	Other Medical Personnel
LI	Lawyer for Insured	PT	Physical Therapist	MS	Medical Specialist
INS	Insurer	PA	Physician's Assistant
SI	Self-Insured	OP	Optometrist	DS	Dental Specialist
IV	Insurance Company Employee	PO	Pedicist
IB	Agent/Broker	RD	Radiologist	NS	Nurse Specialist
IS	Adjuster	MT	Message Therapist
IR	Appraiser	AMB	Ambulance Service Employer	OT	Other
DS	Body Shop	DMP	DMP Supplier
SV	Salvage Yard Owner / Employee	HHA	Home Health Agency
TY	Tow Yard Owner / Employee	MR	Laboratory
MD	Medical Doctor	MH	Medical Clinic/Hospital
DO	Doctor of Osteopathic Medicine	MZ	Office Administrator
DIN	Dentist	BS	Billing Services

Communications are protected under the immunity provisions of R.D. Cent. Code § 26.1-02.1-04

Additional Party Involved / AKA Information
Type:	Name (Last):		(First):		(Middle):		Date of birth:	Age:	SSN:
Street Address (include P.O. Box and apartment #'s):				Address Type: ☐ Res. ☐ Bus. ☐ Maildrop ☐ Other			Fed. TIN ☐ Number:	EIN ☐	Sex: M ☐ F ☐
City:		State:	Zip:	County:		Telephone No.: ( )		Phone Type: ☐ home ☐ cell ☐ bus.
Driver's License #:		State:	VIN:			Telephone No.: ( )		Phone Type: ☐ home ☐ cell ☐ bus.
Vehicle Year:	Make:		Model:		License Plate #:		Reported Injuries:
Employer:			Address & Phone #:				Occupation:
Involvement in referral:
Additional Party Involved / AKA Information
Type:	Name (Last):		(First):		(Middle):		Date of birth:	Age:	SSN:
Street Address (include P.O. Box and apartment #'s):				Address Type: ☐ Res. ☐ Bus. ☐ Maildrop ☐ Other			Fed. TIN ☐ Number:	EIN ☐	Sex: M ☐ F ☐
City:		State:	Zip:	County:		Telephone No.: ( )		Phone Type: ☐ home ☐ cell ☐ bus.
Driver's License #:		State:	VIN:			Telephone No.: ( )		Phone Type: ☐ home ☐ cell ☐ bus.
Vehicle Year:	Make:		Model:		License Plate #:		Reported Injuries:
Employer:			Address & Phone #:				Occupation:
Involvement in referral:
Additional Party Involved / AKA Information
Type:	Name (Last):		(First):		(Middle):		Date of birth:	Age:	SSN:
Street Address (include P.O. Box and apartment #'s):				Address Type: ☐ Res. ☐ Bus. ☐ Maildrop ☐ Other			Fed. TIN ☐ Number:	EIN ☐	Sex: M ☐ F ☐
City:		State:	Zip:	County:		Telephone No.: ( )		Phone Type: ☐ home ☐ cell ☐ bus.
Driver's License #:		State:	VIN:			Telephone No.: ( )		Phone Type: ☐ home ☐ cell ☐ bus.
Vehicle Year:	Make:		Model:		License Plate #:		Reported Injuries:
Employer:			Address & Phone #:				Occupation:
Involvement in referral:
Additional Party Involved / AKA Information
Type:	Name (Last):		(First):		(Middle):		Date of birth:	Age:	SSN:
Street Address (include P.O. Box and apartment #'s):				Address Type: ☐ Res. ☐ Bus. ☐ Maildrop ☐ Other			Fed. TIN ☐ Number:	EIN ☐	Sex: M ☐ F ☐
City:		State:	Zip:	County:		Telephone No.: ( )		Phone Type: ☐ home ☐ cell ☐ bus.
Driver's License #:		State:	VIN:			Telephone No.: ( )		Phone Type: ☐ home ☐ cell ☐ bus.
Vehicle Year:	Make:		Model:		License Plate #:		Reported Injuries:
Employer:			Address & Phone #:				Occupation:
Involvement in referral: