55 Pa. Code § 255.84 - Procedures

(a) Negligence action (third party liability). If medical care is due to an accident or injury for which there is a negligence action or a potential one, the County Assistance Office, provided that the hospital or other provider has not taken an assignment, will approve payment, and refer the situation to claim settlement as specified in § 177.83(reserved). If the hospital takes a subrogation or assignment for damages against the third party to the extent of the hospital bill, the client will not be eligible for Medical Assistance payment of the bill.

(b) Administrative error. Action taken regarding administrative error will be as follows:

(1) If the County Assistance Office erroneously authorizes payments on an invoice when the client is not eligible, and if the facts to determine eligibility were known to the CAO, it will be administrative error. The overpayment will be referred for collection action only if the client had been clearly notified of his ineligibility for Medical Assistance before making the application for coverage represented by the bill.

(2) If a patient was eligible for both Medicare and Medical Assistance and the former was not billed first, an administrative error will exist.

(3) In negligence cases, if the third party was billed on the interim per diem Medical Assistance rate and not the actual charge, an administrative error will exist.

(c) Classification of overpayments. Overpayments, for purposes of administrative action, will be classified either as suspected fraud or nonfraud. The decision as to whether or not the overpayment is suspected fraud or nonfraud will be made by relating the case facts to the definitions and criteria in § 3812.

(d) Investigating overpayments. Action taken regarding Medical Assistance overpayments will be as follows:

(1) The general principles contained in § 255.4 (relating to procedures) will be applicable to investigating overpayments in Medical Assistance.

(2) The County Assistance Office will be responsible for investigating possible overpayments in active and inactive categorically needy and medically needy cases. If the CAO discovers that an MA payment was made after the effective date of ineligibility, the county will submit the necessary information to the claim settlement by means of the Form PA 189.

(3) In considering whether or not an overpayment has occurred, the worker must consider that the person determined ineligible as categorically needy may be eligible as a medically needy person if he meets the eligibility requirements specified in Subparts C and D (relating to eligibility requirements; and determination of need and amount of assistance).

(4) If a person has any type of third party coverage, such as Blue Cross, Medicare, Commercial Hospital Insurance, V.A. Benefits, Workman's Compensation and the like, or personal funds that are available toward the cost of his medical care, and these resources were not used prior to the service, an overpayment will exist.

(5) In preparing the Form PA 93, Sample Data Report, for the 5% sampling of Medical Invoice payments, the County may discover data which indicate possible recipient or provider fraud. When the investigation of the county substantiates that an overpayment occurred, appropriate referral will be made to claim settlement or to the Bureau of Medical Assistance, as specified in subsection (e).

(6) Decedent estate lists received by the County Assistance Office from claim settlement area offices will be cleared through the master files of the county. Cases identified as having received Medical Assistance will be referred back to the area office to check the estate for undeclared assets at the time of application for MA. If an undeclared asset is discovered in the estate, the claim can then be presented to the estate for repayment of the MA received.

(e) Referral for restitution or prosecution. Referral for restitution or prosecution of overpayment claims will be as follows:

(1) The County Assistance Office will refer overpayment claims over $50 resulting from client error or fraud to claim settlement by means of the Form PA 189, Referral for Restitution or Prosecution. The Form PA 189 will be submitted to claim settlement within 30 days from the date the county office receives the information establishing the overpayment.

(2) Supporting documents needed to substantiate the overpayment will be submitted with the Form PA 189.

(3) Overpayments due to provider error or fraud will be referred by memorandum to the Office of Medical Programs, Bureau of Medical Assistance, for appropriate action. The memorandum must contain a complete summary of the facts of the situation needed to substantiate the overpayment. Supporting documents will be submitted with the memorandum to the Bureau of Medical Assistance.

(4) Nonfraud overpayments within the control of the provider for medical care rendered to the medically needy only, or resulting from county administrative error, will be corrected by use of the Form PA 259-C, Request for Correction of Payment, or, if this is not possible, a referral will be made to claim settlement area office.

Notes

55 Pa. Code § 255.84

The provisions of this § 255.84 adopted August 4, 1977, effective 8/5/1977, 7 Pa.B. 2180.

This section cited in 55 Pa. Code § 255.71 (relating to policy); 55 Pa. Code § 255.81 (relating to policy); and 55 Pa. Code § 255.82 (relating to definitions).