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Printed Date: 9/22/2015
Section 935 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) provides limitations on the recoupment of Medicare overpayments.
Overpayments Subject to the Limitation on Recoupment
Overpayments Not Subject to the Limitation on Recoupment
The Medicare appeals process has five levels
A valid redetermination request:
Note: Claims adjusted based on a determination made by CERT or the Recovery Auditor contractor (identified as TOB XXH) cannot be adjusted by the provider or by Palmetto GBA. Therefore, even if you do not dispute the overpayment decision but need to make other corrections to the claim (e.g., to correct a clerical error such as add/remove/change a HCPCS code or modifier), you must submit a redetermination request.
If you do not request a redetermination or make payment in full by the 39th day:
If you do request a redetermination:
Providers are strongly encouraged to submit a redetermination form via Palmetto GBA's eServices. Providers can electronically submit the appeal request and PDF attachments online. Once submitted, you will receive a confirmation from Palmetto GBA indicating that the appeal has been received. For more information, please review the Appeals Section in the eServices User Manual (PDF, 7.79 MB).
Interest Repayment on 935 Overturned Appeals
Interest accrued and collected is refunded for appeals associated with 935 Overpayment Appeals only. If the appeal is favorable or partially favorable, the award amount is applied to the overpayment and interest is recomputed based on the new overpayment amount. If the appeal is a complete reversal, any principle and interest collected is refunded. Any collections exceeding the overpayment balance are refunded to the provider.
The 935 limitation on recoupment provisions changed the way interest is to be paid to a provider whose overpayment determination is overturned at the ALJ level and above. This is referred to as 935 interest, which is payable on an underpayment where the reversal occurs at the ALJ and above levels. The 935 interest is based on the period that Medicare recouped the provider‘s funds. Payment of 935 interest is only applicable to overpayments recovered under the limitation on recoupment provisions. Interest is only payable on the principal amount recouped.
The 935 interest is only paid on involuntary payments, i.e., Medicare funds withheld and applied to the overpayment. If the provider elects to pay the overpayment by check, extended repayment schedule or immediate offsets, the 935 special interest does not apply.
935 Special Interest is computed as follows — (Per IOM 100-6 Chapter 3 200.6.2)
To access online forms, access the Palmetto GBA's Forms application.
CMS Regulation References
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Last Updated: 03/22/2019