Section 702-1-IX - [Effective 1/1/2025] Fraud and IneligibilityA. Definitions: 1. "PFML fraud" exists where a covered individual has obtained paid family or medical leave benefits based upon a willful false statement, willful misrepresentation of a material fact, or the willful withholding of a material fact or facts.2. "Material fact" means a fact the truth or falsity of which would have a determinative effect on the approval or denial of a claim.B. The Department shall investigate complaints or reports of suspected PFML fraud. The Department may also conduct random audits and reviews of submitted claims. A finding of PFML fraud shall be made based on a preponderance of the evidence. The following procedures may be followed in investigations of suspected PFML fraud:1. Obtaining documentary evidence. Prior to interviewing an individual, the Department shall obtain all available documentation. An individual shall provide any requested documents within 21 days of receiving a request from the Department.2. The Department may interview a covered individual after providing notice no less than ten (10) business days in advance. The notice of interview will be provided in writing. The interview may be conducted in person or by phone at the discretion of the Department.3. The Department shall make a finding of PFML fraud or, if fraud is not determined, dismiss the complaint, and shall notify the covered individual as to the outcome of the investigation. If the Department finds that the covered individual has committed PFML fraud, the covered individual's benefits, if currently active, shall immediately be suspended, and the covered individual shall be designated as ineligible pursuant to 26 M.R.S. §850-D(5).C. If the Department determines that PFML fraud has occurred that affected a covered individual but for which the covered individual was not responsible, such as identity theft by a third party, any weeks fraudulently used will not be charged against the covered individual's maximum leave benefits.D. A covered individual found to have committed PFML fraud shall be designated as ineligible pursuant to 26 M.R.S. §850-D (5) and disqualified from benefits for a period of one year from the date of the final determination. The Department may demand repayment of any benefits paid as a result of PFML fraud.E. The Department shall notify the covered individual if it demands repayment of the amount due. The covered individual may request a waiver of repayment by notifying the Department, in writing, within 30 days after the notice of the repayment. The covered individual's request shall state the reasons for requesting a waiver of repayment. The Department shall have the discretion to waive repayment in whole or in part if recovery would be against equity and good conscience.F. A covered individual may appeal a finding of PFML fraud, a demand for repayment, or a denial of a waiver request consistent with the procedures in Section XV of this rule within 15 business days from the date the decision is issued. A request for waiver of repayment does not constitute a request to appeal the demand for repayment unless a request to appeal is specifically included. Any repayment shall be tolled during the pendency of an appeal or a request for waiver. However, absent a showing that it would be against equity and good conscience, the covered individual's designation of ineligibility and immediate termination of current benefits shall not be tolled during the pendency of an appeal.12-702 C.M.R. ch. 1, § IX