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Printed Date: 9/22/2015
Palmetto GBA has identified potential overpayments for claims processed prior to February 2018, related to Part A Jurisdiction J claims that were paid for Medicare beneficiaries covered under an MA Plan. Below, we have listed the limited scenarios that would warrant the claim being submitted to Fee For Service (FFS) Medicare.
For additional information, refer to the full list of exceptions to requirements (PDF, 522 KB) for MA plans to Cover FFS Benefits.
This article serves as our intent to provide notice that we plan to reopen Medicare’s initial determination of claims erroneously paid within four years of the date of this notice (May 7, 2018). The decision to reopen for good cause is in accordance with 42 CFR 405.986 and based on evidence that an obvious error was made at the time of the initial determination. Providers with claims subject to the above reopening will be contacted directly and provided with a claims listing of potential overpayments. If overpayments exist and result in financial hardship, you will be provided with several options for returning overpayments including negotiating an extended repayment plan.
As required by 42 CFR 401.305 a provider/supplier who has received an overpayment must report and return the overpayment within 60 days after having identified the overpayment. (The overpayment can also be reported and returned by the date any corresponding cost report is due, if applicable). This requirement applies to overpayments identified within six years of the date the overpayment was received. In addition, when a government agency informs a provider/supplier of a potential overpayment, the provider/supplier has an obligation to accept the finding or make a reasonable inquiry to determine whether an overpayment exists and whether any similar overpayments exist within the six year lookback period.
6/12/2018: Providers with claims subject to the above reopening will receive a letter dated June 15, 2018 and provided with a claims listing of potential overpayments. If overpayments exist and result in financial hardship, you will be provided with several options for returning overpayments including negotiating an extended repayment plan.
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Last Updated: 06/12/2018