| (a) An MCC may recover a refund due to overpayment
or completion of an audit if:
(1) the MCC notifies the physician or the provider
of the overpayment not later than the 180th day after the date of
receipt of the overpayment; or
(2) the MCC notifies the physician or the provider
of the completion of an audit under §21.2809 of this title (relating
to Audit Procedures).
(b) Notification under subsection (a) of this section
must:
(1) be in written form and include the specific claims
and amounts for which a refund is due, and for each claim, the basis
and specific reasons for the request for refund;
(2) include notice of the physician's or provider's
right to appeal; and
(3) describe the methods by which the MCC intends to
recover the refund.
(c) A physician or a provider may appeal a request
for refund by providing written notice of disagreement with the refund
request not later than 45 days after receipt of notice described in
subsection (a) of this section. On receipt of written notice under
this subsection, the MCC must begin the appeal process provided for
in the MCC's contract with the physician or the provider.
(d) An MCC may not recover a refund under this section
until:
(1) for overpayments, the later of the 45th day after
notification under subsection (a)(1) of this section or the exhaustion
of any physician or provider appeal rights under subsection (c) of
this section, where the physician or the provider has not made arrangements
for payment with an MCC; or
(2) for audits, the later of the 30th day after notification
under subsection (a)(2) of this section or the exhaustion of any physician
or provider appeal rights under subsection (c) of this section, where
the physician or the provider has not made arrangements for payment
with an MCC.
(e) If an MCC is a secondary payor and pays a portion
of a claim that should have been paid by the MCC that is the primary
payor, the secondary payor may only recover overpayment from the MCC
that is primarily responsible for that amount. If the portion of the
claim overpaid by the secondary payor was also paid by the primary
payor, the secondary payor may recover the amount of overpayment from
the physician or the provider that received the payment under the
procedures set out in this section.
(f) Subsections (a) - (e) of this section do not affect
an MCC's ability to recover an overpayment in the case of fraud or
a material misrepresentation by a physician or a provider.
|
