CMS Pub. 100-08, ch. 8, § 8.2.3.1

A. Step 1

The first step in assessing an overpayment is for contractors to document for each claim

reviewed the following:

• The amount of the original claim;

• The allowed amount;

• The rationale for denial;

• The §1879 determination for each assigned claim in the sample denied because

the service was not medically reasonable and necessary (or the §1842(1)

provider/supplier refund determination on non-assigned provider/supplier claims

denied on the basis of §1862 (a)(1)(A)) (refer to Exhibit 14.1 of this manual);

• The §1870 determination for the provider/supplier for each overpaid assigned

claim in the sample (refer to Exhibit 14.2 of this manual); and

• The amount of overpayment (after allowance for deductible and coinsurance).

B. Step 2

Notify the provider/supplier of the preliminary overpayment findings and preliminary

review findings.

C. Step 3

If the provider/supplier submits additional documentation, review the material and adjust

the preliminary overpayment findings, accordingly.

D. Step 4

Calculate the final overpayment.

E. Step 5

Refer to the overpayment recoupment staff.