Citations:

Social Security Act, as amended, Section 1870; 42 CFR 405.350-405.358 and 42 CFR 411.24

BASIC (05-01)

A. DEFINITION OF MEDICARE OVERPAYMENTS

Medicare overpayments are funds a beneficiary has received in excess of amounts due and payable under the Medicare law and regulations.

NOTE: Once an overpayment determination has been made, the amount determined is a debt owed to the United States Government.

B. POLICY

Cross program adjustment is mandatory when the Medicare contractor has not recovered or waived an overpayment.

C. PROCESS--SSA

Overpayments that have not been waived by Medicare contractors are referred to SSA when the contractor cannot recover the overpayment and the amount is $1000.00 or over. If SSA is unable to recover the Medicare overpayment, the case should be returned to the referring agency (Centers for Medicare & Medicaid Services (CMS) Central Office, CMS Regional Office or the Medicare contractor.)

D. PROCESS - MEDICARE CONTRACTOR

When a Medicare overpayment is determined, the contractor sends the required beneficiary notice. This notice includes:

• an explanation of the cause and amount of the overpayment;

• appeal and waiver rights; and

• notification to the beneficiary that the overpayment will be referred to SSA for benefit withholding action if a refund is not received.