Identification Process For Overpayments Sample Clauses

Identification Process For Overpayments a. Hospital is required to report Overpayments to Health Plan by the later of: (i) the date which is sixty (60) calendar days after the date on which the Overpayment was identified; or (ii) the date any corresponding cost report is due, if applicable. A person has identified an Overpayment if the person has actual knowledge of the existence of an Overpayment or acts in reckless disregard or with deliberate indifference of the Overpayment. b. An Overpayment shall be deemed to have been “identified” when: i. Hospital reviews billing or payment records and learns that it incorrectly coded certain services, resulting in increased reimbursement. ii. Hospital learns that a Member death occurred prior to the service date on which a Claim that has been submitted for payment. iii. Hospital learns that Hospital Services were provided by unlicensed or excluded individual on its behalf. iv. Hospital performs an internal audit and discovers that an Overpayment exists. v. Hospital is informed by a government agency of an audit that discovered a potential Overpayment. vi. Hospital is informed by the Health Plan of an audit that discovered a potential Overpayment. vii. Hospital experiences a significant increase in Medicaid revenue and there is no apparent reason – such as a new partner added to a group practice or new focus on a particular area of medicine – for the increase. viii. Hospital has been notified that the Health Plan or a government agency has received a hotline call or email. ix. Hospital has been notified that the Health Plan or a government agency has received information alleging that a recipient had not received services or been supplied goods for which the Hospital submitted a Claim for payment.