Contractor Activities to Support Assessing Overpayment

8.2.3.1 – Contractor Activities to Support Assessing Overpayment (Rev. 670, Issued: 08-19-16, Effective: 11-23-16, Implementation: 11-23-16) A. Step 1 The first step in assessing an overpayment is for contractors to document for each claim reviewed the following: • The amount of the original claim; • The allowed amount; • The rationale for denial; • The §1879 determination for each assigned claim in the sample denied because the service was not medically reasonable and necessary (or the §1842(1) provider/supplier refund determination on non-assigned provider/supplier claims denied on the basis of §1862 (a)(1)(A)) (refer to Exhibit 14.1 of this manual); • The §1870 determination for the provider/supplier for each overpaid assigned claim in the sample (refer to Exhibit 14.2 of this manual); and • The amount of overpayment (after allowance for deductible and coinsurance). B. Step 2 Notify the provider/supplier of the preliminary overpayment findings and preliminary review findings. C. Step 3 If the provider/supplier submits additional documentation, review the material and adjust the preliminary overpayment findings, accordingly. D. Step 4 Calculate the final overpayment. E. Step 5 Refer to the overpayment recoupment staff.