South carolina department of health and human services medicaid policy and procedures manual

101.17 Overpayments/Underpayments (Eff. 10/01/05)

An overpayment may occur because:

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  The beneficiary was ineligible for a period during which he/she received Medicaid benefits; or
  
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  Medicaid paid more for the cost of medical services than it should have.
  

The overpayment could have resulted from agency or beneficiary error. If the overpayment resulted from agency error, the beneficiary is not required to repay the funds. Therefore, no overpayment summary is required. The Medicaid eligibility worker documents the case record with the fact of the agency error and the period of time covered by the overpayment. Examples of agency error are:

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  Failure to take action on reported information
  
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  Failure to follow up on an anticipated change in circumstances
  
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  Failure to redetermine eligibility in a timely manner
  
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  Failure to apply policy or procedures correctly
  

If the overpayment resulted from beneficiary error, an overpayment summary is required. Examples of beneficiary error are:

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  Withholding information
  
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  Providing incorrect information
  
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  Unreported changes
  

The beneficiary may willfully withhold information that he/she knows will affect his eligibility. In this case, refer to MPPM 101.16 in this chapter regarding beneficiary fraud. On questionable cases, the DHHS Division of Program Integrity will determine if information was willfully withheld.

101.17.01 Completing an Overpayment Summary (Rev. 07/01/09)

Once it has been determined that a beneficiary error has occurred resulting in a potential overpayment, the Medicaid eligibility worker must take the following actions:

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  Beneficiary’s name, address and telephone number
  
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  Medicaid ID Number and Social Security Number
  
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  Period covered by the overpayment
  
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  Summary of the facts pertaining to the overpayment including any background information
  
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  Copy of the MEDS Beneficiary Information Screen
  
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  Copy of the application or review, budget sheets, verification documents
  

4. After 10 days, forward the DHHS Form 3252 ME, a copy of DHHS Form 928, and all other attachments to:

Eligibility, Enrollment and Member Services

Department of Technical Assistance

1801 Main Street

Columbia, South Carolina 29202

101.17.02 Repayment of Medicaid Benefits Resulting from an Overpayment (Eff. 10/01/05)

The Division of Program Integrity will determine if the beneficiary owes a refund resulting from an overpayment. The amount owed depends upon whether the beneficiary used his Medicaid card. If it is determined that the beneficiary owes a refund for the error, the beneficiary will receive a letter from the Division of Program Integrity which will include his rights to file an appeal.

101.17.03 Repayment of Medicaid Benefits Resulting from Continued Benefits During an Appeal (Eff. 10/01/05)

If a beneficiary files an appeal and requests continued benefits pending the outcome of an appeal hearing, the DHHS Form 3260 ME, Request for a Fair Hearing, or written notice to receive continued benefits must be in the case record. If the decision upholds the action taken on the case, any Medicaid payments received during this period are subject to repayment. (Refer to MPPM 101.13.04.)

101.18 Healthy Connections (Medicaid) Insurance Card (Eff. 03/01/08)

Medicaid eligible beneficiaries receive a plastic South Carolina Healthy Connections (Medicaid) Insurance Card. The front of the card includes the member’s name, date of birth, and Medicaid health insurance number. The back of the card includes:

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  A number that providers may call for prior authorization of services outside the normal practice pattern or outside a 25-mile radius of South Carolina
  
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  A toll-free number that may be utilized by providers to access the Medicaid IVRS. (Refer to MPPM 101.13.04 for information on IVRS.)
  
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  A magnetic strip that may be utilized by providers in POS devices. (Refer to MPPM 101.13.04 for information on POS services.)
  

Refer to MPPM Chapter 104, Appendix X, for a copy of the Healthy Connections (Medicaid) Insurance Card.