130 CMR, § 450.235

Current through Register 1536, December 6, 2024

Section 450.235 - Overpayments

(A) Overpayments include, but are not limited to, payments to a provider

(1) for services that were not actually provided or that were provided to a person who was not a member on the date of service;

(2) for services that were not payable under MassHealth on the date of service, including services that were payable only when provided by a different provider type and services that were not medically necessary (as defined in 130 CMR 450.204);

(3) in excess of the maximum amount properly payable for the service provided, to the extent of such excess;

(4) for services for which payment has been or should be received from health insurers, worker's compensation insurers, other third-party payers, or members;

(5) for services for which a provider has failed to make, maintain, or produce such records, prescriptions, and other documentary evidence as required by applicable federal and state laws and regulations and contracts;

(6) for services provided when, as of the date of service, the provider was not a participating provider, or was in any breach or default of the provider contract;

(7) for services billed that result in a duplicate payment; or

(8) in an amount that a federal or state agency (other than the MassHealth agency) has determined to be an overpayment.

(B) A provider must report in writing and return any overpayments to the MassHealth agency within 60 days of the provider identifying such overpayment or, for payments subject to reconciliation based on a cost report, by the date any corresponding cost report is due, whichever is later. A provider must include in such written report the reason for the overpayment and use such form and follow such process that may be prescribed by the MassHealth agency.