Some plans exclude coverage for services or supplies that Aetna considers medically necessary. But here was the problem: the MassHealth program didnt provide a meaningful definition of inpatient and outpatient services. N/A. Send Adjustment/Void Request Forms submitted with a REFUND CHECK to: . The materials and information located on the WellCare website are for services rendered prior to May 1, 2021. employees and agents within your organization within the United States and its purpose. Portugus, 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency The Third Party Liability and Recovery Division's Overpayments program (OP) is responsible for enforcing fiscal compliance with Medi-Cal laws and regulations for Medi-Cal providers and beneficiaries. Supporting documentation, including but not limited to: A letter explaining the reason for the refund, A copy of your Explanation of Benefits (EOB) statement, In the case of incorrect coordination of benefits, the primary carrier's EOB statement, Any other documentation that would assist in accurate crediting of the refund. Providers can also choose to return the paper Remittance and Status . Thomas focuses his practice on complex federal and Alexander provides coverage, reimbursement, and compliance strategies advice to a broad range of Erin Estey Hertzog is a partner in Foley Hoag's Healthcare practice. New Claim Refund form Wisconsin Medicaid is introducing the Claim Refund form in conjunction with the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. This requirement of section 1902(a)(30)(A) led to an important decision by the Supreme Judicial Court of Massachusetts in 1999. If you believe an overpayment has been identified in error, you may submit your dispute by fax to 1-866-920-1874 or mail to: There are two ways this can do be done: If the claim is within 3 years of the paid date, submit an adjustment request through the Electronic Data Interchange (EDI) or MITS web portal. IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE for Medicaid purposes the form does not require an expiration date to be valid. This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. A provider must pay, deny, or contest the health insurer's claim for overpayment within 40 days after the receipt of the claim. THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE Forms for Florida Bluemembers enrolled in individual, family and employerplans. If you are currently getting payments and you do not make a full refund, the notice will: propose to withhold the overpayment at the rate of the lesser of 10 percent or the entire monthly payment; state the month the proposed withholding will start; IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Clinical Policy Bulletins (CPBs). Medicare, pharmacy and more. Appointment of Representative Form Courtesy of the Department of Health and Human Services Centers for Medicare & Medicaid Services. Overpayments and Recoupment. CMS regulations provide an answer to this question. Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT), copyright 2015 by the American Medical Association (AMA). Any The Court told the state: The [MassHealth] program may operate on a case-by-case basis to determine the appropriate level of care, defined in some meaningful way, and allow reimbursement at that level, provided there is adequate review of its decision. You will be leaving Sunshine Health internet site to access. 1999), the court assessed a Massachusetts Medicaid (in Massachusetts, Medicaid is called MassHealth) policy under which MassHealth would conduct a retrospective utilization review policy involving admissions for inpatient services for MassHealth patients. (Although as my colleague Ross Margulies has pointed out here, CMS has recently given states some additional flexibilities in this regard). All rights reserved. h Bookmark | BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT. Submit this completed form with all refund checks and supporting documentation to ensure the overpayment refund is processed timely. Use the Claim Status tool to locate the claim you want to appeal or dispute, then select the "Dispute Claim" button on the claim details screen. All rights reserved. Texas is required to report recoveries for these MFCU-determined Medicaid overpayments to the Centers for Medicare & Medicaid Services (CMS) and to refund the Federal share to the Federal Government. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements. Before sending us a check, please consider that your payment may have resulted from applying an MOB provision. Medicaid, or other programs administered by the Centers for Medicare and CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Contact Information. Call TTY +1 800-325-0778 if you're deaf or hard of hearing. And then finally, states have one year from the date that they discover an overpayment to return the federal share of the overpayment to CMS. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. The decision of the Massachusetts Supreme Court decision in that case, the prior SJC decision, and a very recent Wisconsin Supreme Court decision illustrate the limits that states must contend with as they attempt to do so. MassHealth insisted that its policy was mandated by section 1902(a)(30)(A); how else, the state argued, could Massachusetts safeguard against unnecessary utilization of care and services under the state plan? consequential damages arising out of the use of such information or material. Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). in the absence of any other carrier. RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. And as we said at the outset of this article, we think that states are likely to be more aggressive in discovering overpayments as finances continue to be tight and Medicaid enrollment continues to grow post-COVID. The AMA is a third party beneficiary to this Agreement. employees and agents are authorized to use CDT only as contained in the Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites. The ADA does not directly or indirectly practice medicine or dispense dental services. Sunshine Health is a managed care plan with a Florida Medicaid contract. For specific details, please refer to the Allwell from Sunshine provider manual. Measurement-Based Care in Behavioral Health, Medical Policies (Medical Coverage Guidelines), Medical Policy, Pre-Certification, Pre-Authorization, 835 Health Care Electronic Remittance Advice Request Form, Billing Authorization for Professional Associations, Contraceptive Tier Exception Request Instructions, CVS Caremark Specialty Pharmacy Enrollment Form, Electronic Funds Transfer Registration Form, Hospital, Ancillary Facility and Supplier Business Application, Independent Dispute Resolution 30-Day Negotiation Request Form, Medicare Advantage Waiver of Liability Form for Non-Contracted Providers, Medicare Clinical Care Programs Referral Form, Member Discharge from PCP Practice (HMO and BlueMedicare HMO only), National Provider Identifier (NPI) Notification Form, Notice of Medicare Non Coverage Form Instructions, Physician and Group Request to Participate Form, Preservice Fax Cover Sheet for Medical Records, Provider Reconsideration/Administrative Appeal Form, Skilled Nursing Facility Select Medication Program Order Form, Nondiscrimination and Accessibility Notice. Massachusetts has since revised its regulations, but this leads us to the second topic we wanted to discuss today, and that is: what happens (for example, under the MassHealth policy before it was invalidated) when a state Medicaid plan identifies an overpayment? In other words, since the federal government has skin in the game by way of the federal matching payment CMS has an interest in ensuring that states are responsible with those matching funds. repay the $851,842 Federal share of Florida State Medicaid overpayment collections during the 2 State fiscal years (July 1, 2010, through June 30, 2012) after our . The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. Just enter your mobile number and well text you a link to download the Aetna Health app from the App Store or on Google Play. By clicking on I accept, I acknowledge and accept that: Licensee's use and interpretation of the American Society of Addiction Medicines ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits. U.S. Government rights to use, modify, reproduce, , All Rights Reserved. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Form DFS-AA-4 Rev. Reasonable Effort Documentation . Options must be selected; if none are checked, the form will be rejected. ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING. PO Box 957352 The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. agreement. Member Grievance and Appeals Request Form ( English | Spanish) Medical Release Form ( English | Spanish) Authorization for the Use and Disclosure of PHI ( English | Spanish) Member access to PHI ( English | Spanish) Freedom of Choice ( English | Spanish) Real Time Reporting PDN Member Letter. All services deemed "never effective" are excluded from coverage. Members should discuss any matters related to their coverage or condition with their treating provider. MZsOR3ff&&qA~N#% ;>%k:M/V/lTeFk:5^>`u D0 Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. At the time, the states regulations simply defined inpatient services as services that were provided on an inpatient basis. Required fields are marked *. CMS DISCLAIMS Return of Monies to Medicare Form Instructions. Claims and payments. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. Simply Healthcare Plans, Inc. P.O. Provider Services and Complaints Policy (PDF). For help in applying for Medicaid, contact 1-800-362-1504. If you are uncertain that prior authorization is needed, please submit a request for an accurate response. REFUND CHECK # _____ The AMA does The AMA is a third party beneficiary to this Agreement. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. We then pay the difference. The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. Subject to the terms and conditions contained in this Agreement, you, your 256 0 obj <>stream To dispute an overpayment identified in a demand letter use the appropriate. 04/2014 . CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. Do you want to continue? Refund Policy The refund process of your payment will begin upon receipt of the Application for Refund form. Unlisted, unspecified and nonspecific codes should be avoided. Box 933657 Atlanta, GA 31193-3657. Applicable FARS/DFARS restrictions apply to government use. Taxpayers use Form 843 to claim a refund (or abatement) of certain overpaid (or over-assessed) taxes, interest, penalties, and additions to tax. Use this form for CAAP Debt Dispute overpayments (Covid Advance Payments). Download the free version of Adobe Reader. MOB provision: $370 bill results in $65.70 Aetna normal benefit. Refunds/Overpayments Forms. DFARS 227.7202-3(a )June 1995), as applicable for U.S. Department of Defense Medicaid services to recover, or to attempt to recover, such overpayment before making an adjustment to refund the Federal share of the overpayment. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. N/A. The Office of Medicaid Program Integrity audits and investigates providers suspected of overbilling or defrauding Florida's Medicaid program, recovers overpayments, issues administrative sanctions, and refers cases of suspected fraud for criminal investigation. It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan. Providers can offset overpaid claims against a future payment. not directly or indirectly practice medicine or dispense medical services. 4c Return of State WarrantCheck this option if the State Warrant is enclosed. While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. The date that a federal official has identified the overpayment. implied, including but not limited to, the implied warranties of Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). This product includes CPT which is commercial technical data and/or computer Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. New and revised codes are added to the CPBs as they are updated.