NC Medicaid has contracted with Health Management Systems (HMS) to conduct Overpayment Recovery Reviews for NC Medicaid Direct beneficiaries.
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.
NC Medicaid’s objective is to identify and recover overpayments determined to be refundable to the Medicaid program.
Definition of a Medicaid Overpayment
A Medicaid overpayment is a payment a provider receives in excess of the amounts properly payable under Medicaid statutes and regulations. Once NC Medicaid, the recovery vendor or the provider identifies an overpayment, the overpayment amount becomes a debt owed to the NC Medicaid. Federal law requires that states timely attempt recovery of all identified overpayments.
In Medicaid, overpayments commonly occur due to:
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Duplicate submission of the same service or claim;
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Furnishing and billing for excessive or non-covered services; or
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Payment to the incorrect payee.
Overpayment Collection Process
When NC Medicaid discovers an overpayment, the Medicaid Administrative Contractor 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 the payment or dispute is not received in 30 days, then HMS will adjust the claim(s) to recover the overpayment on the provider’s account.
NC Medicaid prefers that a provider submit adjusted claims to return the overpayment to the State; however, if an adjusted or voided claim cannot be submitted electronically NC Medicaid will accept payment via a physical check.
Please follow the NCTracks Provider refund form instructions.
Contact
Please contact the Credit Balance Audit team with questions at 916-912-4651 or at nccba@gainwelltechnologies.com.