Claims and Appeals

Limitation on Recoupment

Section 1893 (f)(2)(a) of the Social Security Act provides limitations on the recoupment of Medicare overpayments. Noridian will stop all recoupment activities upon the receipt of a valid and timely redetermination or reconsideration request; however, collection activities will continue if a valid appeal is filed to the Administrative Law Judge, Medicare Appeals Council, or Federal court. Both principal and interest collected on the overpayment will be refunded for any overturned appeal decisions.

Overpayments Subject to Limitation on Recoupment Overpayments Not Subject to Limitation on Recoupment
  • Post Pay Denials of claims
    • Recovery Audit Contractor (RAC)
    • Office of Inspector General (OIG) determined overpayments
    • Comprehensive Error Rate Testing (CERT)
    • Supplemental Medicare Review Contractors (SMRC)
    • Unified Program Integrity Contractor (UPIC)
  • Medicare Secondary Payer (MSP) Duplicate Primary Payment (DPP)
  • MSP recovery due to provider's failure to file a proper claim with third-party payer plan, program, or insurer for payment
  • Final Claims associated with a Home Health Agency (HA) Request for Anticipated Payment (RAP) under Home Health Prospective Payment System (HH PPS)
  • All other Medicare Secondary Payer recoveries except those identified in left column
  • Beneficiary overpayments
  • Overpayments that arise from a cost report determination
  • HHA Request for Anticipated Payment (RAP)
  • Hospice Caps calculations
  • Provider initiated adjustments
  • Accelerated/Advance Payments
  • Reopening of claims (Clerical errors and mass adjustments)
  • Periodic Interim Payments (PIP) rate adjustments (except for a RAC claim review, which determines and creates an overpayment)
  • Payment Suspensions

 

Request a Redetermination

Timeframe Provider/Supplier Action Recoupment
Day 1 Receives notification via mail of overpayment determination N/A
Day 1-15 Must submit rebuttal request within 15 days from demand letter date Collection does not occur
Day 1-40 May appeal and potentially limit recoupment from occurring Collection does not occur
Day 41 May appeal and potentially stop recoupment Unless a valid appeal is received, collection begins

 

  • Electronic Submission

    • Submit via NMP. It's fast, secure and economical - Log In Now
      • Access educational resources, learn how to register, and view user manual on NMP webpage

  • Paper Submission

    • Access Medicare DME Redetermination Request Form or CMS-20027 Medicare Redetermination Request Form - One request form per beneficiary and claim control number (CCN)
    • Complete all form fields. An incomplete request will be dismissed
      • Be sure to check "Yes" in Overpayment Appeal section of "Medicare DME Redetermination Request Form" or "Does this appeal involve and overpayment?" box in CMS-20027 "Medicare DME Redetermination Request Form"
    • Submit completed form and copy of supplier demand letter to correct address/fax number
      • See form for fax number or Mailing Addresses webpage for "Overpayment Redetermination and Rebuttal Requests" postal address

See the Redetermination webpage for additional first level of an appeal related details.

Request a Reconsideration

Unless a reconsideration is filed with the Qualified Independent Contractor (QIC), payment is made in full or a valid extended repayment schedule (ERS) has been received, collection process will continue on any existing debt within 60 days of the Redetermination notice.

Interest will continue to accrue as of the demand letter date.

See the Reconsideration webpage for additional second level of an appeal related details.

Immediate Recoupment

Medicare allows suppliers to sign up for Immediate Recoupment, a process which allows overpayments to be automatically recouped from currently processed and paid claims. View the Immediate Recoupment or Offset webpage for details.

Resources

 

Last Updated Wed, 05 Feb 2020 16:07:14 +0000