C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-1, subsec. 144-101-I-1.12
Under certain circumstances, an adjustment may be made on the billing claim form or on electronically filed claims to reverse or to reverse and replace a claim. Providers must comply with the most current billing instructions issued by the Department.
When, as the result of an audit, the Department determines that an underpayment has been made to a provider, the Department will notify the provider and send written authorization allowing the provider to bill MaineCare.
If a provider believes an underpayment has been made for covered services rendered, based upon policy and procedures as described in thisManual, the provider should accept and cash the check issued for the services provided. The provider must request a review of payments, using the MaineCare Adjustment Request form, within one hundred and twenty (120) days of the remittance statement date or waive any right to a review of that payment. MaineCare Adjustment Request forms are available at https://mainecare.maine.gov/Provider%20Forms/Forms/Publication1.aspx?RootFolder=%2fProvider%20Forms%2fClaims&FolderCTID=&View=%7b55EF7D29%2d59ED%2d4CC1%2dA015%2d69037A886B14%7d .
An overpayment from MaineCare may indicate that a provider has submitted bills and/or received payment to which he or she is not properly entitled.
Failure to reimburse the Department for an overpayment may result in provider sanctions, as detailed in the Social Security Act, Title XI, § 1128 J(d). These sanctions are described in Section 1.20.
Unless other regulations apply, the provider must reimburse the Department within thirty (30) calendar days of the date of the notice of the overpayment.
The Department may withhold payment on pending claims and on subsequently received claims for the amount of the overpayment when overpayments are not repaid as required in Section 1.12-2(C)(1) in accordance with state and federal rules and regulations. The Department may offset and/or recoup against MaineCare providers related by ownership and control to the provider that owes a collectible debt as defined in Title 22, section 1714- A(2). Providers are related by ownership and control only if the relationship allows the person whose relationship is the subject of the offset to control at least the number of votes of the Provider's governing body or management that is needed to govern the operation of the Provider.
The Department may file a civil action in the appropriate Court and exercise all other civil remedies available to the Department in order to recover the amount of an overpayment.
Pursuant to 22 M.R.S. §1714-A the Department may recover the amount of an established debt through lien and foreclosure thirty-one (31) calendar days after exhaustion of all administrative appeals and any judicial reviews under 5 M.R.S. §8001et seq.
Providers shall submit adjustment requests, which require review by MaineCare Services, on a MaineCare Adjustment Request form with appropriate documentation and a new claim form.
Some examples for use of this form are: the provider is requesting additional funds on a previously paid claim, an original claim was denied as a duplicate, medical necessity/medical review is required, and Prior Authorization is required. Providers have one hundred twenty (120) days from the date of the remittance statement to submit the MaineCare Adjustment Request form.
C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-1, subsec. 144-101-I-1.12