CMS Pub. 100-06, ch. 3, § 200.5.3

Decision

(Rev.12509; Isuued:02-15-24; Effective: 07-01-24; Implementation: 07-01-24)

Contractors work the debt immediately upon receipt of the effectuation notice from the

Administrative Qualified Independent Contractor (QIC) or other notification of the

Decision outcome to complete the computation and the effectuation, as applicable.

Contractors adjust the claim(s) in the claims history system for the finalized claim

payment, effectuate, and refund the amounts recouped on the favorable claims. This

process is completed within 30 calendar days starting from the final determination (Final

claims adjustment date) to the manual invoice

entry date in HIGLAS.

Contractors shall perform the following steps after receipt of the effectuation notice

from the Administrative QIC related to fully and partially favorable decisions:

1. Contractors shall use the following suppression code when adjusting the claim

(claim history) to prevent adjustments from going to HIGLAS.

• Part B uses the ‘Y’ suppression on the adjusted claim to prevent the

adjustment from going to HIGLAS.

• Part A uses the ‘A’ tape to tape flag on the adjusted claim to prevent the

Adjustment from going to HIGLAS.

• DMAC's use “P” and “B” adjustment force codes to the adjusted claim in VMS

To prevent the adjustment from going to HIGLAS.

2. Effectuate any overpayments or refunds after the contractor computes the amount

for Any adjustments or payment to the provider. For additional guidelines refer to

Chapter 29, Section 330.4 - Effectuation Time Limits & Responsibilities.

3. Recalculate the overpayment and update the AR/s in HIGLAS and create a manual

invoice to refund the provider within 30 calendar days. This timeframe begins at the

final claims adjustment date to the entry date of the manual invoice.

Note: With the exception of extrapolations, the timeframe is 30 calendar days from the

receipt of the recalculation amounts. The process begins once the appeal decision is

received, the decision and claim information are sent to the appropriate contractor for the

recalculation of the extrapolation. Once the recalculation is completed and returned, the

MAC effectuates the decision i.e., adjusting the balance of the AR in HIGLAS, issuing a

recalculation letter or issuing a refund as needed.

Note: For extrapolations, the timeframe is 30 calendar days from the receipt of the Unified

Program Integrity Contractor (UPIC) and the Office of the Inspector General (OIG)

recalculations.

4. Issue a Revised Overpayment Demand Letter when there is a new revised amount,

and an open balance remains.

a. There may be circumstances when a Fully Favorable decision outcome creates

a remaining balance.

• If this occurs contractors shall need to send a Revised Overpayment

Demand Letter to address this action.

b. When the intent to refer letter (ITR) was previously sent:

• Include language that refers the provider back to the initial ITR.

c. For Fully Favorable decisions without an open balance remaining, the

Remittance Advice (RA) shall be acceptable in place of additional written notices.

d. Follow the same instructions as in Publication 100.06, Chapter 4 to proceed

with referring the remaining balance to Treasury.

3. Contractors shall use Exhibit 5 as an example and at their discretion, change the

language to address the overpayment accordingly, as needed.

Use the appropriate appeal level within the content of the letter:

a. Medicare Administrative Law Judge (ALJ)

b. Departmental Appeals Board (DAB)

c. Federal court levels.

C. Fully Unfavorable Appeal Decision:

1. When the ALJ issues an unfavorable decision:

a. Contractors shall update the status of the AR and send the Revised Overpayment

letter on open balances only after a Fully Unfavorable decision within 30-calendar

days starting from the receipt date available in the MAS.

b. Contractors shall be able to access reports in MAS, which identifies the

unfavorable ALJ appeal decisions.

• All ALJ level information in MAS is available once the ALJ level record is

closed and ECAPE close web service has transferred data to MAS.

2. Contractor shall refer any outstanding debt to Treasury within 30 calendar days

following the unfavorable decisions notifications for the ALJ or subsequent levels

based on the ITR previously sent.