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West Virginia Income Maintenance Manual Chapter 11

West Virginia Income Maintenance Manual

Page 28 Chapter 11 Benefit Repayment

11.4 MEDICAID CLAIMS AND REPAYMENT PROCEDURES This section describes the procedures for establishing claims and collecting repayments for Medicaid services. 11.4.1 REPAYMENT OF CORRECTLY PAID BENEFITS – ESTATE RECOVERY Under certain circumstances, the Department of Human Services (DOHS) must be reimbursed for Medicaid expenditures made on behalf of an eligible client. Repayment of correctly paid benefits is required only for those who received nursing facility services, Home and Community- Based (HCB) Waiver, Traumatic Brain Injury (TBI) Waiver, Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), and related hospital and prescription drug services. The Bureau for Medical Services (BMS) is responsible for implementing this law. Any inquiries are referred to the BMS’ Estate Recovery contract agency at (304) 342-1604 or 1 (877) 598-5220. 11.4.2 REPAYMENT OF BENEFITS FOR WHICH CLIENT WAS INELIGIBLE When it is determined that the client was ineligible for Medicaid and that the DOHS paid for medical services, the action depends upon whether or not the claim is due to intentional misrepresentation. 11.4.2.A Intentional Misrepresentation When intentional misrepresentation is suspected and the amount of the medical payment is $500 or more, the case is referred to Investigations and Fraud Management (IFM) for investigation, using the IFM-1. Prior to the IFM referral, the Worker must determine that payment for medical services was made by the Department. The Worker must request such information from BMS in writing. The Medical Processing Unit produces a printout of the paid Medicaid expenses. This printout must be attached to the IFM-1. The Worker takes no further action on the claim. If the IFM Investigator notifies the Worker that prosecution is not being pursued, the instructions in item B below are used.