Administrative Review

(1) Surcharge Liability. EOHHS may conduct an administrative review of surcharge liability payments at any time. (2) Reviews and Audits. In conducting such review, EOHHS will review data submitted by hospitals, ambulatory surgical centers, and any other relevant data, including surcharge data. All information provided by, or required from, any payer, pursuant to 101 CMR 516 will be subject to audit by EOHHS. For surcharge liability payments based upon a global fee or capitation payment allocated according to an allocation method accepted by EOHHS pursuant to 101 CMR 516.03(4)(b), EOHHS’ review will be limited to determining whether this method was followed accurately and whether the amounts reported were accurate. (a) EOHHS may require the payer to submit additional documentation reconciling the data it submitted with data received from hospitals and ambulatory surgical centers. (b) If EOHHS determines through its review that a payer's surcharge liability payment was materially incorrect, EOHHS will require a payment adjustment. (3) Notification. EOHHS will notify the payer in writing if it determines there should be a payment adjustment. The notification will include a detailed explanation of the proposed adjustment. (4) Objection Process. A payer may object to proposed adjustment in writing, within 15 business days of the mailing of the notification letter. The payer may request an extension of this period for cause. The written objection must, at a minimum, contain: (a) the specific reason(s) for each of the payer's objections; and (b) all documentation that supports the payer's position. (5) Written Determination. Following review of the payer's objection, EOHHS will notify the payer of its determination in writing, with an explanation of its reasoning. (6) Payment of Adjustment Amounts. Payment of adjustment amounts are due within 30 days following the mailing of the determination letter.