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MEDICAL SERVICES POLICY MANUAL,SECTION M M-100 Overpayments M 110 Overpayments Due to Ineligibility

M-100 Overpayments

MS Manual 01/01/14 Any medical payment made on behalf of and to the benefit of an individual which is in excess (by at least $5.00) of the amount that should have been paid (if any) is an overpayment. It exists for each month that the individual received benefit of such payment. An overpayment may result from an individual giving fraudulent information, withholding information, failing to report a change, etc. or from the Agency failing to exercise proper diligence, or a combination of factors. The amount of overpayment will be determined using the budgetary procedures and allowances in effect at the time the overpayment occurred.

M-110 Overpayments Due to Ineligibility MS Manual 01/01/14 • When ineligibility of a case or member occurs, the potential for Medicaid overpayment is created. To determine if an overpayment has occurred, the ineligible case/members will be evaluated using Medically Needy criteria. A potential overpayment has occurred when the Medically Needy evaluation results in: • Excess Income; • Excess Resources; or • Individuals who cannot be included in an MN determination. • For reporting of potential overpayments, refer to the following: • When an understated liability exists in an LTC case, refer to MS M-120. • When excess income exists, refer to MS M-130. • When excess resources exist, refer to MS M-140. • When individuals cannot be included, refer to MS M-160. An overpayment occurs when medical payments have been made on behalf of individuals in any month the individuals are found not eligible.

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Page 375

Official source

MEDICAL SERVICES POLICY MANUAL,SECTION M M-100 Overpayments M 110 Overpayments Due to Ineligibility

M-100 Overpayments

MS Manual 01/01/14 Any medical payment made on behalf of and to the benefit of an individual which is in excess (by at least $5.00) of the amount that should have been paid (if any) is an overpayment. It exists for each month that the individual received benefit of such payment. An overpayment may result from an individual giving fraudulent information, withholding information, failing to report a change, etc. or from the Agency failing to exercise proper diligence, or a combination of factors. The amount of overpayment will be determined using the budgetary procedures and allowances in effect at the time the overpayment occurred.

M-110 Overpayments Due to Ineligibility MS Manual 01/01/14 • When ineligibility of a case or member occurs, the potential for Medicaid overpayment is created. To determine if an overpayment has occurred, the ineligible case/members will be evaluated using Medically Needy criteria. A potential overpayment has occurred when the Medically Needy evaluation results in: • Excess Income; • Excess Resources; or • Individuals who cannot be included in an MN determination. • For reporting of potential overpayments, refer to the following: • When an understated liability exists in an LTC case, refer to MS M-120. • When excess income exists, refer to MS M-130. • When excess resources exist, refer to MS M-140. • When individuals cannot be included, refer to MS M-160. An overpayment occurs when medical payments have been made on behalf of individuals in any month the individuals are found not eligible.