Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 450.000 - Administrative and Billing Regulations
Section 450.235 - Overpayments
Universal Citation: 130 MA Code of Regs 130.450
Current through Register 1531, September 27, 2024
(A) Overpayments include, but are not limited to, payments to a provider
(1) for services
that were not actually provided or that were provided to a person who was not a
member on the date of service;
(2)
for services that were not payable under MassHealth on the date of service,
including services that were payable only when provided by a different provider
type and services that were not medically necessary (as defined in 130 CMR
450.204);
(3) in excess of the
maximum amount properly payable for the service provided, to the extent of such
excess;
(4) for services for which
payment has been or should be received from health insurers, worker's
compensation insurers, other third-party payers, or members;
(5) for services for which a provider has
failed to make, maintain, or produce such records, prescriptions, and other
documentary evidence as required by applicable federal and state laws and
regulations and contracts;
(6) for
services provided when, as of the date of service, the provider was not a
participating provider, or was in any breach or default of the provider
contract;
(7) for services billed
that result in a duplicate payment; or
(8) in an amount that a federal or state
agency (other than the MassHealth agency) has determined to be an
overpayment.
(B) A provider must report in writing and return any overpayments to the MassHealth agency within 60 days of the provider identifying such overpayment or, for payments subject to reconciliation based on a cost report, by the date any corresponding cost report is due, whichever is later. A provider must include in such written report the reason for the overpayment and use such form and follow such process that may be prescribed by the MassHealth agency.
Disclaimer: These regulations may not be the most recent version. Massachusetts may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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