Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.237 - Overpayments: Determination

Current through Register 1525, July 5, 2024
The existence and amount of overpayment may be determined in an
				action to recover the overpayment in any court having jurisdiction. The
				MassHealth agency may also determine the existence and amount of overpayments.
				The procedures described in
				130 CMR
				450.236 and 450.237 do not apply to
				overpayments resulting from rate adjustments, which are governed by methods
				described in
				130 CMR
				450.259.
(A)
Overpayment
			 Notice
. When the MassHealth agency believes that an overpayment
			 has been made, it notifies the provider in writing of the facts upon which the
			 MassHealth agency bases its belief, identifying the amount believed to have
			 been overpaid and the reasons for concluding that such amount constitutes an
			 overpayment. When the overpayment amount is based on a determination by a
			 federal or state agency (other than the MassHealth agency), the MassHealth
			 agency will so inform the provider. The MassHealth agency may notify the
			 provider by letter, draft audit report, computer printout, or other
			 format.
(B)
Timely
			 Reply
. To preserve its right to an adjudicatory hearing and
			 judicial review, the provider must reply in writing to the MassHealth agency
			 and such reply must be received by the MassHealth agency within 30 calendar
			 days of the date on the overpayment notice. The reply must specifically
			 identify and address all allegations in the overpayment notice with which the
			 provider disagrees. With the reply, the provider may submit additional data and
			 argument to support its claim for payment and must include any documentary
			 evidence it wants the MassHealth agency to consider. If the MassHealth agency
			 states in the overpayment notice that the overpayment amount is based on a
			 determination by a federal or state agency (other than the MassHealth agency),
			 a provider may contest only the factual assertion that the federal or state
			 agency made such a determination. The provider may not contest in any
			 proceeding before or against the MassHealth agency the amount or basis for such
			 determination.
(C)
Overpayment Determination
. The MassHealth agency
			 considers and reviews only information submitted with a timely reply. If, after
			 reviewing the provider's reply, the MassHealth agency determines that the
			 provider has been overpaid, the MassHealth agency will so notify the provider
			 in writing of its final determination, which will state the amount of
			 overpayment that the MassHealth agency will recover from the
			 provider.
(D)
Adjudicatory Hearing
. If the provider submits a timely
			 reply, the provider may file a claim for an adjudicatory hearing to appeal the
			 MassHealth agency's final determination, in accordance with
			 130 CMR
			 450.241 and
			 450.243.
(E)
Consequences of Failure to
			 Submit a Timely Reply
. The provider has no right to an
			 adjudicatory hearing or judical review if it fails to submit a timely reply.
			 The MassHealth agency will take appropriate action to recover the
			 overpayment.