7 AAC 43.081. Recovery of an overpayment

(a) An overpayment occurs when the division reimburses a provider

(1) for a service without prior authorization when prior authorization is required under this chapter;

(2) in an amount that exceeds the maximum dollars or units allowed under this chapter;

(3) for a service not covered under this chapter;

(4) for a service not authorized under the provider's current provider agreement;

(5) for a service paid for by another source, or a service eligible for payment by another source;

(6) in an amount the provider or the division identifies as an overpayment;

(7) in excess of the amount due because of an error or omission of an automated claims processing system;

(8) incorrectly for services that do not meet standards established for reimbursement of services;

(9) that is not certified for participation in the Medicaid program;

(10) for a service already reimbursed by the Medicaid program;

(11) for a service provided to a recipient ineligible for the Medicaid program;

(12) for a service provided to a recipient eligible for Medicaid, but ineligible for the service billed to the Medicaid program; or

(13) in excess of the amount due because of the billing practices of the provider.

(b) The division will, in its discretion,

(1) recoup an overpayment from a provider, without notice to the provider other than as provided by (c) of this section, by reducing future payments to the provider until the overpaid amount has been offset; or

(2) arrange with the provider the terms of the provider's repayment of the overpayment.

(1) not more than 120 days after the overpayment, the division shall notify the provider by remittance advice;

(2) more than 120 days after the overpayment, the division shall notify the provider in writing at least 30 days before recoupment of the overpayment begins.

(d) When the division recovers an overpayment under (b)(2) of this section, the division shall notify the provider in writing at least 30 days before recovery of the overpayment begins.

(e) The division's remittance advice or notice under (c) or (d) of this section must provide to the provider

(1) the reason for the recoupment or recovery;

(2) the amount of the overpayment that the division will recoup or recover; and

(3) notice of the provider's right to obtain a review under 7 AAC 43.083 or appeal under 7 AAC 43.085.

(f) If, following receipt of a remittance advice or notice under (c) or (d) of this section, the provider discontinues billing the division for Medicaid services, the division shall make a written demand to the provider for repayment of the balance of the overpayment.

(g) This section does not apply

(1) to probate collections, actions under 7 AAC 43.950 - 7 AAC 43.985, or bankrupt or out-of-business providers;

(2) to recoupment that is based solely on a prospective payment rate under 7 AAC 43.670 - 7 AAC 43.709.

History: Eff. 11/29/97, Register 144; am 6/26/98, Register 146

Authority: AS 47.05.010

AS 47.07.030

AS 47.07.040

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