Cal. Code Regs. Tit. 22, § 51458.1 - Cause for Recovery of Provider Overpayments

(a) The Department shall recover overpayments to providers including, but not limited to, payments determined to be:

(1) In excess of program payment ceilings or allowable costs.

(2) In excess of the amounts usually charged by a provider.

(3) For services not documented in the provider's records, or for services where the provider's documentation justifies only a lower level of payment.

(4) Based upon false or incorrect claims or cost reports from providers.

(5) For services deemed to have been excessive, medically unnecessary or inappropriate.

(6) For services prescribed, ordered or rendered by persons who did not meet the standards for participation in the Medi-Cal program at the time the services were prescribed, ordered or rendered.

(7) For services not covered by the program.

(8) For services to persons not eligible for program coverage when the services were provided.

(9) For Medi-Cal covered services already paid for by the beneficiary, but not yet refunded, or for services already reimbursed by the Department or other coverage.

(10) For services that should have been billed to other coverage.

(11) For services not ordered or prescribed, when an order or prescription is required.

(12) For services not authorized, when a treatment authorization request is required.

(13) In violation of any other Medi-Cal regulation where overpayment has occurred.

(b) The provisions of Sections 51488 and 51488.1 shall prevail in circumstances that conflict with this section.

Notes

Cal. Code Regs. Tit. 22, § 51458.1

1. New section filed 12-31-80; effective thirtieth day thereafter (Register 81, No. 1).
2. Editorial correction of NOTE (Register 84, No. 35).
3. Editorial correction of subsection (a)(9) (Register 95, No. 45).
4. Change without regulatory effect amending NOTE filed 12-16-2013 pursuant to section 100, title 1, California Code of Regulations (Register 2013, No. 51).

Note: Authority cited: Section 20, Health and Safety Code; and Sections 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 14005, 14005.1, 14005.4, 14005.8, 14018, 14019, 14021, 14024, 14026, 14053, 14103.2, 14103.6, 14105, 14107, 14110.1, 14117, 14123, 14124.1, 14124.2, 14124.24, 14124.5, 14131, 14132, 14133, 14133.1, 14170, 14176 and 14177, Welfare and Institutions Code.

1. New section filed 12-31-80; effective thirtieth day thereafter (Register 81, No. 1).
2. Editorial correction of NOTE (Register 84, No. 35).
3. Editorial correction of subsection (a)(9) (Register 95, No. 45).
4. Change without regulatory effect amending Note filed 12-16-2013 pursuant to section 100, title 1, California Code of Regulations (Register 2013, No. 51).