Current through Register Vol. XLI, No. 50, December 13, 2024
Section 85-28-3 - Overpayments: Notification and Reconsideration3.1. Notification of decision. The Commission shall notify each health care vendor of any alleged overpayment by United States mail, first class, postage pre-paid. 3.1.a. In overpayment matters the notification shall detail and provide an itemized statement of the alleged overpayment and the audit reason.3.1.b. The notification shall include language to inform the health care provider that it is afforded the right to file a request for reconsideration of the decision and provide an address where the request for reconsideration shall be filed.3.1.c. The notification may be sent by the Commission's agent. The notification may require that the request for reconsideration be filed with the Commission's agent or the Commission as specified in the notification.3.2. Undisputed amounts. If the findings of overpayment contained within the notification are not disputed by the health care vendor, then the health care vendor is required to remit payment in full within sixty (60) calendar days of the notification date. 3.2.a. Upon receipt of a request from the health care vendor and a showing of undue hardship, the Commission may enter into a repayment agreement with the health care provider. The repayment agreement shall not extend for a period in excess of twelve (12) months and shall provide for the payment of principal and interest. Interest shall be calculated in the same manner as provided in the provisions of W. Va. Code § 23-2-13.3.3. Request for reconsideration. Each health care provider who desires to dispute an overpayment decision is required to file a complete and timely request for reconsideration as a condition precedent to filing a petition for hearing.3.4. Time limits. A request for reconsideration shall be filed with the Commission within thirty (30) days of the health care provider's receipt of notice of the disputed Commission's decision or action or, in the absence of such a receipt, within sixty (60) days of the date of the Commission's making such disputed decision or taking such disputed action. Such time limitations are a condition of the right to litigate the decision or action and are jurisdictional.3.5. Contents of the request for reconsideration. In its request for reconsideration, the health care provider shall clearly identify the decision or action disputed. The health care provider shall also clearly identify the bases upon which the health care provider disputes the decision or action.3.6. Review. Upon the filing of a health care provider's request for reconsideration, the Commission or its agent shall review the bases for the request. Such a review may include a meeting with the health care provider, a review of the health care provider's records, or any other process calculated to provide the Commission with the relevant information necessary to perform its review. After reviewing the request, the Commission shall enter its final decision. 3.6.a. The Commission is required to enter a final decision or enter into an extension agreement with the health care provider within one hundred-twenty (120) days from the date the provider's request for reconsideration is filed.3.6.b. The Commission and the health care provider may enter into a written extension agreement to provide no more than an additional sixty (60) days for the Commission to enter a final decision.3.6.c. The Commission's failure to enter a final decision within the initial time period or extended time period, where applicable, triggers a health care provider's right to file a petition for hearing.3.7. Effect of filing. The filing of a timely and complete request for reconsideration of a written decision or action of the Commission stays the tolling of the time limitations for filing a petition for hearing until the final decision is issued.3.8. Example. The health care provider receives a decision from the Commission. The health care provider desires to dispute the decision or action. The health care provider must file a request for reconsideration of the decision or action and await the Commission's final decision in the matter, the expiration of the one hundred-twenty (120) day period for the Commission to issue a final decision, or the expiration of such additional written time extension agreement as limited by this rule. The final decision may be contested by filing a petition for hearing. Should the health care provider fail to file a timely and complete request for reconsideration, then the Commission's decision or action becomes final.