Incarceration Claim Denials
Update October 2014
Some providers will be receiving a refund payment dated October 2014 for additional claims that have recently been refunded. Noridian has processed these refunds and have reprocessed the claims. These payments will be reflected on your remittance advice and the claims history will reflect these adjustments.
If you disagree with the claim repayment amount or refund amount, you may submit a Redetermination [PDF] request. Be sure to include a copy of the letter with your request.
Update May 2014
Providers should be receiving a refund check dated April/May 2014, for the additional claims that were NOT refunded due to system constraints. Noridian has processed these funds and have reprocessed the claims. These payments will not be sent out on your remittance advice but the claims history will reflect these adjustments.
If you are expecting to receive a refund check and haven't received a deposit/check yet, please wait until the end of May 2014. A courtesy letter detailing the affected accounts receivables will be sent out separately by the end of May 2014 as well. If you haven't received the payment or the detailed letter by the end of May 2014, call the Provider Contact Center.
If you disagree with the claim repayment amount or refund amount and wish to file an appeal, you should file a request for redetermination. The Redeterminations address is available on the Mailing Addresses webpage.
For additional information on how to file an appeal, refer to the following link:
Providers should have received a refund check dated December 4, 2013, for claims that denied incorrectly due to the information listed in the "History" section below. There were other claims that were NOT refunded due to system constraints and Noridian is currently in the process of refunding providers for those funds and reprocessing the claims. This process will take some time due to the large quantity of claims and they have to be manually adjusted. This process will also occur in two parts for each claim and will be occurring until approximately April 2014.
First, providers will receive a payment that may contain single to multiple claim refunds. Second, these reprocessed claims will have a letter generated with a listing of the claims that providers will use to match the dollar amounts paid to the claims. Providers may contact the Provider Contact Center if assistance is needed in identifying the name of the patient using the Financial Control Number (FCN) on the listing. Providers will NOT receive a corrected remittance advice (RA) for these claims. A further explanation of why a corrected RA will not be issued, as well as an example of the letter being sent to providers, can be viewed in the below PDF. We ask providers to please be patient until all claims are reprocessed and to monitor this webpage for updates as we will post the completion date of this process.
Medicare will generally not pay for medical items and services furnished to a beneficiary who was incarcerated or in custody under a penal statute or rule at the time items and services were furnished. In the summer of 2013, CMS initiated recoveries from providers and suppliers based on data that indicated a beneficiary was incarcerated or in custody on the date of service. For these recoveries, they identified previously paid claims that contained a date of service that partially or fully overlaps a period when a beneficiary was apparently incarcerated based on information from the Social Security Administration (SSA). As a result, a number of overpayments were identified. In some cases, demand letters were released with appeal instructions, while in other cases, automatic collections of overpayments were made. CMS has since learned that the information was, in certain situations, incomplete for purposes of collection.
This issue has recently been corrected and payments were sent on the majority of claims affected. A detailed letter including the affected accounts receivables will be sent out by the end of December 2013. If you have received payment but do not receive this letter by the end of December 2013, call the Provider Contact Center.
There will be more claims manually reviewed and corrected which may result in additional payments. Once these manual adjustments have been made, notification will be sent.
CMS understands that this issue has been challenging for providers and beneficiaries.
Last Updated Oct 25, 2019