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PDFWAC 182-502-0230

Provider overpayment disputesGeneral.

(1) This section applies to provider overpayment disputes with providers who furnish health care services to Washington apple health clients, except those overpayment disputes to which chapter 182-502A WAC applies. For the purposes of this section:
(a) "Agency" means the health care authority and its designees.
(b) "Provider" has the same meaning as vendor in RCW 41.05A.010(5).
(2) If the medicaid agency determines that a provider was overpaid, the agency may take any of the following actions:
(a) Review claims, encounters, or payments;
(b) Refer the provider to the agency's office of program integrity;
(c) Refer the provider to the Washington state medicaid fraud control unit;
(d) Refer the provider to the appropriate state health care professional discipline authority;
(e) Terminate the provider's participation in Washington apple health;
(f) Assess a civil penalty against the provider, per RCW 74.09.210;
(g) In the event of a prepay review, suspend some or all payments;
(h) Adjust or void an improper claim, encounter, or payment;
(i) Recover any moneys that the provider received as a result of overpayments as authorized under chapter 41.05A RCW; and
(j) Any other action authorized by Title 182 WAC.
(3) A provider may contest an overpayment by requesting a hearing.
(4) The hearing request must:
(a) Be in writing;
(b) Identify each overpayment being contested;
(c) State each reason why the provider thinks the overpayment is incorrect;
(d) Include documentation to support the provider's position; and
(e) Include a copy of the overpayment notice.
(5) The hearing request must be served on the agency at the address specified in the overpayment notice, in a manner which provides proof of receipt, no later than twenty-eight calendar days after the provider received the overpayment notice.
(6) The hearing is conducted under the Administrative Procedure Act and chapter 182-526 WAC.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-01-056, § 182-502-0230, filed 12/10/14, effective 1/10/15. WSR 11-14-075, recodified as § 182-502-0230, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0230, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.520, 34.05.020, 34.05.220. WSR 00-22-017, § 388-502-0230, filed 10/20/00, effective 11/20/00. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-502-0230, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-042.]
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