Recovery Where the Beneficiary Is Covered Under Medicaid or

110.1 - Recovery Where the Beneficiary Is Covered Under Medicaid or Another Health Insurance Plan, Private or Governmental (Rev. 13183; Issued: 04-24-25; Effective: 05-27-25; Implementation: 05-27-25) When the contractor determines the beneficiary is liable, and the beneficiary carries supplemental health insurance or is covered by another Government health benefits program such as Medicaid, TRICARE, CHAMPVA, or the Federal Employees Health Benefits Program, it may be possible to recover the overpayment from the other plan or program. Payments of deductible or coinsurance amounts and payment for services rendered persons who are not entitled to Medicare are the payments most likely to be recoverable. If, based on the circumstances of the overpayment the contractor has knowledge of the other plan or program and the contractor believes there is a possibility that the other plan or program will refund the overpayment, it shall attempt to recover from the other plan or program. In this connection, it may be necessary to ask the beneficiary for their policy number or other information concerning their non- Medicare coverage. (See Medicare Claims Processing, Chapter 28, Coordination with Medigap, Medicaid, and Other Complementary Insurers, for procedures to follow where the overpayment is for services that should have been paid for by a WC carrier.) To facilitate recovery of the Medicare overpayments to the extent possible, where another plan or program is involved, the contractor shall attempt to work out mutually satisfactory arrangements with the other carrier(s). In negotiations with Medicaid agencies or carriers, it may be helpful for the contractor to point out that Medicare will refund directly to Medicaid agencies overpayments for services reimbursed on a charge basis. The methods listed below have been used successfully. The contractor shall use any one or a combination, as it finds appropriate. The most desirable method in each situation depends upon the individual circumstances and the provisions of the other plan or program. • The contractor shall arrange with the other plan or program for direct refund of overpayments. If the contractor is also the carrier under the other plan or program, a transfer of funds is the most convenient method of recovering. If another insurance carrier is involved, the contractor shall send the other insurance carrier a letter requesting refund of the overpayment. The letter should explain how the overpayment occurred and how it was calculated. The contractor shall follow up in 30 days with another letter or a phone call if payment or a letter of explanation has not been received. If this does not bring a meaningful response, it shall write to the President or Chief Administrative Officer of the other carrier. • If the contractor does not use the above method for provider overpayments, it shall arrange with the other plan or program to make payment to overpaid provider upon the contractor’s request, (even though the provider has not billed the other plan or program) and to notify the contractor of the payment. Upon receiving such a notice, the contractor shall recover the Medicare overpayment from the provider. • Where neither of the above methods is possible, the contractor shall ask the provider if it would be willing to refund the overpayment and to bill the other plan or program, with the understanding that if it is unable to obtain payment, the contractor will refund the amount recovered to the provider. If the provider does not agree to refund the overpayment before collecting from the other plan or program, the contractor shall ask it to bill the other plan or program and to use the payment to refund the overpayment. If the contractor receives notice that a provider (or a beneficiary) plans to file a claim with another plan or program, it shall suspend recovery efforts for a reasonable period. If the contractor has questions concerning the proper approach in recovering from a welfare agency, or another insurance plan, it should contact its RO. If efforts to recover the overpayment are not successful, or if the contractor is certain that the other plan or program will not refund a particular overpayment, it shall seek recovery from the beneficiary in accordance with §110.2 of this chapter. It shall explain in the notice to the beneficiary that the other plan or program will not make payment directly to it. However, if the beneficiary is a Medicaid recipient, the contractor shall not attempt recovery from the beneficiary.