Provider Reviews and Overpayment Recovery Sample Clauses

Provider Reviews and Overpayment Recovery.  The CHC-MCO must report to the Department within sixty (60) calendar days when it has identified the capitation payments or other payments in excess of amounts specified in the Agreement.  The CHC-MCO shall audit, review and investigate Providers within its Network. The CHC-MCO shall recover any overpayments directly from its Network Providers for audits, reviews or investigations conducted solely by the CHC-MCO. o The CHC-MCO will void Encounters for those claims involving full recovery of the payment and adjust Encounters for partial recoveries. o The CHC-MCO must report all voids and adjustments to Encounters to the Department.  The Department may audit, review and investigate MA Providers within the CHC-MCO’s Network. o The CHC-MCO will coordinate audits, reviews or investigations of Network Providers with the Department to avoid duplication of effort. o The CHC-MCO cannot initiate a review of a Network Provider after the Department advises the CHC-MCO of an open review or investigation by the Department, its representative, or another Federal or State agency, without written Departmental authorization toproceed. o The Department will inform the CHC-MCO of its findings related to Network Providers. o The CHC-MCO must submit an annual report of overpayment recoveries as required in 42 C.F.R. § 438.608(d)(3). o The CHC-MCO must recover overpayments identified by the Department from its Network Provider after the CHC-MCO receives the final results of the Department review. o The Department will deduct the overpayment amount from future payments to the CHC-MCO after ninety (90) days from the mailing date of the final result of the review.  The Department may require the CHC-MCO to suspend payment to a Network Provider or to initiate a pre-payment review as a result of law enforcement reviews and activities or the Department’s audits, reviews or investigations.  The Department may agree to joint reviews, audits or investigations with the CHC-MCO or any CMS contractor. Any recoveries as a result of an agreed upon joint audit, review or investigation shall be shared equally between the CHC-MCO and Department after payment to any CMS contractor.
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Provider Reviews and Overpayment Recovery. The CHC-MCO shall audit, review and investigate Providers/Participants/caregivers within its Network through prepayment and retrospective payment reviews. The CHC- MCO shall cost avoid or recover any overpayments directly from its Network Providers for audits, reviews or investigations conducted solely by the CHC-MCO or through Network Provider self-audits. o The CHC-MCO must notify BPI in writing when it plans to recover and when it has recovered overpayments or improper payments related to Fraud, Abuse or Waste of Medical Assistance services. o The CHC-MCO will void Encounters for those claims involving full recovery of the payment and adjust Encounters for partial recoveries. o The CHC-MCO must report all voids and adjustments to Encounters to the Department. • The Department may audit, review and investigate Providers/Participants/caregivers within the CHC-MCO’s Network.
Sample 1

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