Author: NC Medicaid Third Party Recovery, (919) 527-7690
North Carolina’s Department of Health and Human Services, Division of Health Benefits (DHB) has contracted with Health Management Systems (HMS) to conduct Overpayment Recovery Reviews for Medicaid/Health Choice recipients.
Pursuant to SEC. 1866 [42 U.S.C. 1395cc] providers are required to make adequate provision for return of any moneys incorrectly collected from such individual or other person.
DHB’s objective is to identify and recover overpayments determined to be refundable to the Medicaid/Health Choice programs.
Definition of a Medicaid Overpayment
A Medicaid overpayment is a payment you receive in excess of the amounts properly payable under Medicaid statutes and regulations. Once Medicaid, the recovery vendor or the provider identifies an overpayment, the overpayment amount becomes a debt you owe to the N.C. Medicaid program. Federal law requires states timely attempt recovery of all identified overpayments.
In Medicaid, overpayments commonly occur due to:
- Duplicate submission of the same service or claim;
- Furnishing and billing for excessive or non-covered services; or
- Payment to the incorrect payee.
Overpayment Collection Process
When Medicaid discovers an overpayment, the Medicaid Administrative Contractor, Health Management Systems (HMS) initiates the overpayment recovery process by sending notification to the provider via the HMS Provider Portal. The provider has 30 days to dispute or issue payment for the overpayment. If payment or dispute is not received in 30 days, then the Contractor will adjust the claim(s) to recover the overpayment on the provider’s account.
We prefer that a provider submit adjusted claims to return the overpayment to the State; however, if an adjusted or voided claim cannot be submitted electronically we will accept payment via a physical check.
Please follow the NCTracks Provider refund form instructions found at the following website:
https://www.nctracks.nc.gov/content/public/providers/provider-manuals.html
If you have questions, please contact the Credit Balance Audit team, Michael Flynn at 919-909-5339 or by email at Michael.flynn@hms.com .