Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter I - Specific Policies By Service › Sec2 144-101-I-1 - GENERAL ADMINISTRATIVE POLICIES AND PROCEDURES › Subsection 144-101-I-1.12 - CLAIM ADJUSTMENTS

Current through 2024-29, July 17, 2024
Under certain circumstances, an adjustment may be made
						on the billing claim form or on electronically filed claims to reverse or to
						reverse and replace a claim. Providers must comply with the most current
						billing instructions issued by the Department.
1.12-1
Underpayments
When, as the result of an audit, the Department
						determines that an underpayment has been made to a provider, the Department
						will notify the provider and send written authorization allowing the provider
						to bill MaineCare.
If a provider believes an underpayment has been made for
						covered services rendered, based upon policy and procedures as described in
						thisManual, the provider should accept and cash the check issued for the
						services provided. The provider must request a review of payments, using the
						MaineCare Adjustment Request form, within one hundred and twenty (120) days of
						the remittance statement date or waive any right to a review of that payment.
						MaineCare Adjustment Request forms are available at
https://mainecare.maine.gov/Provider%20Forms/Forms/Publication1.aspx?RootFolder=%2fProvider%20Forms%2fClaims&FolderCTID=&View=%7b55EF7D29%2d59ED%2d4CC1%2dA015%2d69037A886B14%7d
.
1.12-2
Overpayments
An overpayment from MaineCare may indicate that a
						provider has submitted bills and/or received payment to which he or she is not
						properly entitled.
A. When, as a
					 result of an audit, review or other information, the Department determines that
					 it has overpaid a provider, the Department will notify the provider, in
					 writing, as to the nature of the discrepancy, the method of computing the
					 reasonable dollar amount to be refunded and of any further action.
B. Provider Determination of Overpayment.
					 When a provider determines that an overpayment has been made, the provider
					 shall comply with the most recent reimbursement instructions issued by the
					 Department. Overpayments must be reported to the Department within thirty (30)
					 days of identification and repaid in accordance with Title XI, § 1128 J(d)
					 of the
Social Security Act
within sixty (60) days or by the
					 date any corresponding cost report, if applicable, is due, whichever is later.
Failure to reimburse the Department for an overpayment
						may result in provider sanctions, as detailed in the
Social Security
						Act
, Title XI, § 1128 J(d). These sanctions are described in
						Section
						1.20.
C. The Department or its Authorized Entity
					 may recover overpayments made to a provider through direct reimbursement,
					 offset, civil action or other actions authorized by law, pursuant to Title 22,
					 M.R.S. § 1714- A, including interest on overpayments.
1.
Direct Reimbursement
Unless other regulations apply, the provider must
						reimburse the Department within thirty (30) calendar days of the date of the
						notice of the overpayment.
2.
Offset/Recoupment
The Department may withhold payment on pending claims
						and on subsequently received claims for the amount of the overpayment when
						overpayments are not repaid as required in Section 1.12-2(C)(1) in accordance
						with state and federal rules and regulations. The Department may offset and/or
						recoup against MaineCare providers related by ownership and control to the
						provider that owes a collectible debt as defined in Title 22, section 1714-
						A(2). Providers are related by ownership and control only if the relationship
						allows the person whose relationship is the subject of the offset to control at
						least the number of votes of the Provider's governing body or management that
						is needed to govern the operation of the Provider.
3.
Civil Action
The Department may file a civil action in the
						appropriate Court and exercise all other civil remedies available to the
						Department in order to recover the amount of an overpayment.
4.
Liens and Foreclosure
Pursuant to
						22 M.R.S.
						§1714-A the Department may recover the
						amount of an established debt through lien and foreclosure thirty-one (31)
						calendar days after exhaustion of all administrative appeals and any judicial
						reviews under
						5 M.R.S. §8001
et seq
.