Section 7 AAC 105.260 - Recouping an overpayment(a) An overpayment occurs when the department pays a provider (1) for a service without prior authorization when prior authorization is required under 7 AAC 105 - 7 AAC 160;(2) an amount that exceeds the maximum dollars or units allowed under 7 AAC 105 - 7 AAC 160;(3) for a service not covered under 7 AAC 105 - 7 AAC 160;(4) for a service not authorized under the provider's current provider agreement;(5) for a service paid for by another source, or a service eligible for payment by another source;(6) in an amount the provider or the department identifies as an overpayment;(7) in excess of the amount due because of an error or omission of an automated claims processing system;(8) incorrectly for services that do not meet standards established for payment of services;(9) who is not an enrolled Medicaid provider;(10) for a service already paid by the department;(11) for a service provided to a recipient ineligible for Medicaid under AS 47.07 and 7 AAC 100;(12) for a service provided to a recipient eligible for Medicaid under AS 47.07 and 7 AAC 100, but ineligible for the service billed to the department;(13) in excess of the amount due because of the billing practices of the provider; or(14) for a service that was not rendered.(b) The department may (1) recoup an overpayment from a provider, without notice to the provider other than as provided by (c) of this section, by reducing future payments to the provider until the overpaid amount has been offset; or(2) arrange with the provider the terms of the provider's repayment of the overpayment.(c) Before the department (1) recoups an overpayment more than 120 days after the date of the overpayment under (b)(1) of this section, the department will notify the provider in writing at least 60 days before recoupment of the overpayment begins; or(2) recoups an overpayment under (b)(2) of this section, the department will notify the provider in writing at least 60 days before recoupment of the overpayment begins.(d) In the notice under (c) of this section, the department will include (1) the reason for the recoupment;(2) the amount of the overpayment that the department will recoup; and(3) notice of the provider's right to an appeal under 7 AAC 105.270.(e) If, following receipt of a notice under (c) of this section, the provider discontinues billing the department for Medicaid services, the department will send a written demand to the provider for repayment of the balance of the overpayment.(f) This section does not apply to (1) actions under 7 AAC 105.400 - 7 AAC 105.490, or bankrupt or out-of-business providers;(2) recoupment that is based solely on a prospective payment rate under 7 AAC 150;(3) recoupment actions identified in an audit under 7 AAC 160.100 - 7 AAC 160.130.(4) recoupment actions identified in an independent certified audit under 7 AAC 150.180(l) with respect to a hospital receiving payments as a disproportionate share hospital (DSH).Eff. 2/1/2010, Register 193; am 10/1/2011, Register 199; am 5/11/2012, Register 202; am 9/1/2013, Register 207; am 1/1/2024, Register 248, January 2024Authority:AS 47.05.010
AS 47.05.200
AS 47.07.030
AS 47.07.040