Medicaid Policy                                                                 

825-4 Referral for Investigation or Calculation

Effective Date: October 1, 2010

Previous Policy

 

Refer all overpayments and understatements of liability for an investigation or an overpayment calculation.   There are no limits on the time between the occurrence of the overpayment or understatement of liability and the date of the referral.

1. When you do not have the necessary evidence for an overpayment or understated liability calculation referral, refer the situation for an investigation.   (Submitting an investigation referral)

2. When you receive the investigator’s report, take appropriate action on any currently open programs.  The Benefit Accuracy Analyst will receive a copy of the investigation report, too, and decide how or whether to calculate an overpayment.

3. When you have enough evidence for a calculation without asking for an investigation, refer the situation to a Benefit Accuracy Analyst.

The Benefit Accuracy Analyst will:

• Calculate the amount of the error.

• Apply an overstated liability to the overpayment or understatement of liability if the situation that resulted in the overpayment or understatement of liability also involves an overstated liability.

• Refer any resulting refunds to the Office of Finance in Health Care Financing, DHHS. (Search e-Docs for Form 79R) (eRep - Medical Refund Request– Form 79R)

• Refer the overpayment or understatement of liability for adjudication when appropriate.