Overpayments

(A) Overpayments include, but are not limited to, payments to a provider (1) for services that were not actually provided or that were provided to a person who was not a member on the date of service; (2) for services that were not payable under MassHealth on the date of service, including services that do not comply with applicable program regulations or managed care performance specifications, services that were payable only when provided by a different provider type, and services that were not medically necessary (as defined in 130 CMR 450.204); (3) in excess of the maximum amount properly payable for the service provided, to the extent of such excess; (4) for services for which payment has been or should be received from health insurers, worker's compensation insurers, other third-party payers, or members; (5) for services for which a provider has failed to make, maintain, or produce such records, prescriptions, and other documentary evidence as required by applicable federal and state laws and regulations and contracts; (6) for services provided when, as of the date of service, the provider was not a participating provider, or was in any breach or default of the provider contract; (7) for services billed that result in a duplicate payment; or (8) in an amount that a federal or state agency (other than the MassHealth agency) has determined to be an overpayment. (B) A provider must report in writing and return any overpayments to the MassHealth agency within 60 days of the provider identifying such overpayment or, for payments subject to reconciliation based on a cost report, by the date any corresponding cost report is due, whichever is later. A provider must include in such written report the reason for the overpayment and use such form and follow such process that may be prescribed by the MassHealth agency. 2. Administrative Regulations