AddToAny share buttons

Credit Balance Audits Update

NC Medicaid has contracted with Health Management Systems to conduct Overpayment Recovery Reviews for Medicaid beneficiaries.

Note: This bulletin updates and replaces the Credit Balance Audits bulletin published on May 1, 2019.

This bulletin applies to NC Medicaid Direct.

NC Medicaid has contracted with Health Management Systems (HMS) to conduct Overpayment Recovery Reviews for Medicaid beneficiaries enrolled in NC Medicaid Direct.

Pursuant to Section 1866 of the Social Security Act, 42 U.S.C. § 1395cc, providers are required to make adequate provision for the refund of any amounts improperly collected from an 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, its’ recovery vendor or the provider identifies an overpayment, the overpayment amount becomes a debt owed to the NC 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 or billing for excessive or non-covered services; or
  • Payment to the incorrect payee.

Overpayment Collection Process

When NC Medicaid discovers an overpayment, HMS, on behalf of NC Medicaid, initiates the overpayment recovery process by sending notification to the provider via the HMS Provider Portal at https://ecenter.hmsy.com/.

The first step in the process is for the provider to submit their information so that an access request can be created and approved. After that is completed, the provider will receive the appropriate portal link and user guidance.

To obtain access to the CBA Provider Portal, providers are asked to submit the below required information to NCCBAPortal@gainwelltechnologies.com. Please see the information required for Provider access request, including:

  • Provider Name: 
  • Provider State:
  • User’s Name : 
  • User’s Phone Number: 
  • User’s Email Address: 
  • User’s Managers Name: 
  • User’s Managers Phone Number: 
  • User’s Managers Email: 
  • Does User have prior access to the CBA or HMS Provider Portal(s) - Y/N:

Once the information is received:

  1. An access request will be submitted on the provider's behalf.
  2. After the request is approved, the provider will receive an email notification from iamadmin_donotreply@gainwelltechnologies.com.
  3. Once the access setup is complete, the provider will receive an additional email containing: 
    • Portal access confirmation
    • A user manual with instructions on how to use the portal
    • The link to access the portal (included in the manual)

Please note that the HMS Provider Portal and the Credit Balance Audit Provider Portal are two separate portals. This process is for NC Medicaid Direct providers only.

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.

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 found on the NCTracks Provider Policies, Manuals, Guidelines and Forms webpage.

Questions and Contact Information

If you have questions, please contact 916-912-4651 or email CBANCMEDICAID@gainwelltechnologies.com.

A response should be provided within two business days (excluding holidays).

Related Topics: