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The overpayment resulted because the beneficiary had paid the provider more than the deductible, co-payment, or other cost-sharing amounts and this was not indicated on the claim.
The payment was based on an amount in excess of that allowable.
The provider received and retained duplicate payments.
The overpayment was due to a mathematical or clerical error; e.g., an error in calculation of overlapping or duplicate bills. This does not include a failure to properly assess the deductible, where a provider has been incorrectly paid a deductible.
The overpayment was for non-covered services or supplies.
The services or supplies were furnished by a provider not authorized under the policy plan.
The beneficiary and the provider were paid for the same services, resulting in a duplicate payment, and the beneficiary turned his or her payment over to the provider.
The payment was made to the participating provider and a primary health insurance plan also made a benefit payment to the provider or beneficiary for the same services or supplies, and the combined payments exceed the billed charges.
The payment was made to the wrong provider or to a non-participating provider. In such cases, the contractor shall issue payment to the correct payee and initiate recoupment action against the erroneously paid provider concurrently.
The overpayment was caused by incorrect application of the deductible, co-payment or other cost-share.
The patient was not an eligible beneficiary at the time services were provided and the payment was made to a participating provider for whom a good faith payment has been authorized.
A provider who received a duplicate payment certifies the payment was refunded to the beneficiary.
The payment was made to the beneficiary and his or her primary health insurance plan made a benefit payment for the same services or supplies.
The payment was made to the beneficiary instead of the non-network participating provider. The contractor shall immediately issue payment to the non-network participating provider and concurrently take recoupment action against the beneficiary.
Any other instance in which the erroneous payment was made directly to the beneficiary.
If the contractor determines that liability for an overpayment rests with a beneficiary or provider who is deceased, the contractor shall seek recoupment of the overpayment from the estate of the deceased person under state laws.
An ineligible patient holds an ID card showing eligibility and the provider excercised reasonable care in accepting the apparently valid ID card as evidence of eligibility;
An ineligible patient see a resource sharing provider and there is evidence indicating the patient had been shown as eligible at the time of service; or
An ineligible beneficiary enrolls, claims are filed and denied as ineligible, and the contractor can document via evidence that the individual had in fact been shown on as eligible on the date of enrollment and for the period covering the dates of the medical care.
Whether the claim is initially paid or denied, the provider is expected to make a reasonable efforts to collect payment from the ineligible patient prior to requesting approval of a good faith payment.
If the contractor made payment to the participating provider, the contractor shall advise the participating provider and the patient of the patient's ineligibility and then follow recoupment procedures. If, during the recoupment process, the participating provider alleges that he or she relied on the information on the patient's ID card showing eligibility, the contractor shall forward the file to beneficiary and provider services, for consideration of a good faith payment and advise the participating provider of the action taken. The file shall include documentation of all contact with the participating provider of the action taken. The file shall include documentation of all contact with the participating provider and patient.
If the famous people contractor has not made payment to the participating provider, the contractor shall deny the claim based upon ineligibility of the patient.
If the participating provider alleges that he or she relied on the information on the patient's ID card showing eligibility, the contractor shall forward the file to beneficiary and provider services, TMA and advise the participating provider of the action taken. The file shall include documentation of all contacts with the participating provider and patient.
A provider who erroneously furnishes services and/or supplies to an ineligible beneficiary as a result of careless identification procedures is not entitled to a good faith payment.
OVERPAYMENTS RESULTING FROM ALLEGED MISINFORMATION
DENIAL OF BENEFITS PREVIOUSLY PROVIDED
DOUBLE COVERAGE SITUATIONS - PRIMARY HEALTH INSURANCE PLAN LIABLE