CMS Pub. 100-06, ch. 3, § 200.2.4

Suspended funds involving providers, physicians and suppliers who have been put on

payment suspension under 405.372 (e) not a “recoupment” for purposes of the limitation

on recoupment. Suspended funds is not a “recoupment” as this term is defined in

§405.370. CMS is only limited by section 1893(f)(2) of the Act from recouping

Medicare payments. We are not restricted in our ability to apply suspended funds to

reduce or dispose of an overpayment. The Provider cannot appeal a payment

suspension; only the resulting overpayment determination, may be appealed and

subjected to limitation on recoupment.

Exception: If the suspended payments are insufficient to fully eliminate any

overpayment, and the provider or supplier meets the requirements of 42 CFR § 405.379

"Limitation on Recoupment" provision under §1893(f)(2) of the act will be owed to

Medicare.

200.2.5 Timeframe for Stopping Recoupment After a Redetermination

Request is Received

(Rev. 311, Issued: 02-22-19, Effective: 10-07-19, Implementation: 10-07-19)

Contractors’ corporate mailroom receives and stamps the date of receipt on each appeal

request. The timeframe begins in the corporate mailroom starting with the stamped

receipt/date. The date for filing a request is defined as the date it was received by the

appropriate contractor in the corporate mailroom, the date received via facsimile, or the

date received in the secure internet portal/application in accordance with Publication 100-

04, Chapter 29, § 310.2.

Note: If the appeal request is not readily identifiable as such in the corporate mailroom

the date for filing a request is defined as the date the Medicare Contractor identifies the

correspondence as an appeal request. In such instances Contractors must ensure

documentation is maintained on file justifying the alternate appeal request date.

Contractors shall implement the following upon receipt of a Redetermination

Request:

A. Contractors shall take eight (8) business days when the redetermination

request is received on or after calendar day 31 to do the following:

1. Stamp the receipt date in mailroom

2. Review and validate the appeal request; and

3. Set the redetermination status to avoid/stop recoupment. (If the debt is

under an immediate recoupment agreement, the recoupment continues

and in the appeal status at the same time)

Note: Providers run the risk at having recoupments occurring when the

request is received on or after day 31. When a recoupment occurs on

day 41 or later, the contractor shall apply the amounts to

the overpayment and not refund those amounts.

B. Contractors shall have an exception to the eight (8) business day

requirement when the Redetermination request received prior to calendar day

31:

• Contractors shall have the additional time to process a

redetermination request when received prior to calendar day 31

(from the date of the demand letter).

• The additional time shall not exceed (2-3 calendar days)

before day 41 from the demand letter date to update systems

(HIGLAS, MCS, VMS) timely to avoid systematic offset/

recoupments of the provider’s overpayment.

C. Contractors shall have seven (7) additional business days (from the

redetermination appeal status update) to generate and send the

redetermination receipt notice to provider.

D. Contractors shall communicate and coordinate between the appropriate

operational areas, immediately following all validation(s), on 935 overpayment

appeal requests.

E. Contractors shall have internal controls in place after the appeal

validations for updating the redetermination status to stop recoupment from

occurring on day 41.

• When the provider has an immediate recoupment agreement in

place this shall continue with the appeal status update, unless the

provider request the immediate recoupment to stop).

• Contractors shall update the appropriate systems (e.g., HIGLAS

or VMS) to reflect the redetermination appeal status, to prevents

further recoupments from occurring after day 41.

• Contractors on HIGLAS shall update closed debts to reflect the

redetermination appeal status for tracking purposes.