(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).