How to Determine the Fifth Calendar Year after the Year the Payment Was

80.1 – How to Determine the Fifth Calendar Year after the Year the Payment Was Approved (Rev. 294, Issued: 10-06-17, Effective: 07-03-17, Implementation: 07-03-17) Only the year of the payment and the year it was found to be an overpayment enter into the determination of the 5-calendar year period. The day and the month are irrelevant. With respect to payments made in 2016, the fifth calendar year thereafter is 2021. For payments made in 2017, the fifth calendar year thereafter is 2022, etc. Thus, the rules apply to payments made in 2016 and discovered to be overpayments after 2021, to payments made in 2017 and discovered to be overpayments after 2022, etc. Where an overpayment to a provider, or a physician assignee for medically unnecessary services or custodial care is discovered (i.e., demanded) subsequent to the fifth calendar year after the year in which the payment was approved, the provider or physician assignee is prohibited from charging the beneficiary or any other person for the services notwithstanding the fact that the provider or physician assignee has refunded the overpayment if: • The provider or physician assignee was at fault with respect to the overpayment; and • The beneficiary was without fault with respect to the overpayment. (Where the overpayment is discovered in, or before, the fifth calendar year, an "at fault" provider or physician assignee is not prohibited from charging the beneficiary for the overpayment if it has refunded it. However, a without fault beneficiary who pays an at fault provider's or physician assignee’s bill for medically unnecessary services or custodial care, can be indemnified in accordance with Medicare Claims Processing Manual, Publication 100-04, Chapter 30, Financial Liability Protections. Reopenings (See Medicare Claims Processing Manual, Publication 100-04, Chapter 29 Appeals of Claims Decisions for additional information) Your initial, or review determination or a decision by a Hearing Officer may be reopened under the following conditions: Within 12 months after the date of the determination or decision it may be reopened for any reason; After such 12-month period, but within 4 years after the date of the initial determination, it may be reopened for good cause; or At any time, if: - Such initial or review determination was procured by fraud or similar fault of the beneficiary or some other person. If an overpayment is determined based on a reopening outside of the above parameters, the contractor will not recover the overpayment.