CHAPTER 613
S.P. 627 - L.D. 1695
An Act To Ensure Compliance with Federal Medicaid Requirements
Be it enacted by the People of the State of Maine as follows:
Sec. 1. 22 MRSA §13, sub-§6, as enacted by PL 2003, c. 419, §1, is amended to read:
6. Limitation on actions to recover overpayments. The department may impose a sanction or withhold payment from a MaineCare provider in order to recover or impose penalties for an overpayment for services rendered or goods delivered under the MaineCare program as provided in this subsection.
A. The department may impose a sanction or withhold payment when the department has obtained an order from Superior Court allowing interim sanctions upon showing a substantial likelihood that overpayment or and fraud has occurred or that substantial harm to the department will result from further delay or when the department has taken final agency action and the provider has waived or exhausted its right to judicial review.
B. Notwithstanding paragraph A, the department may terminate or suspend the participation of a provider in the MaineCare program in lieu of recoupment pending final determination regarding an overpayment as long as 30 days' notice is given pursuant to federal regulation and state rule.
C. For the purposes of this subsection, "overpayment" does not include an overestimate made as part of a prospective interim payment, a 3rd-party liability recovery, a departmental administrative error or receivership fees or debt. In addition, this subsection does not apply to routine adjustments of $2,500 or less that result from claims editing or processing.
Sec. 2. 22 MRSA §42, sub-§7, ¶H, as enacted by PL 2003, c. 419, §2, is amended to read:
H. In an administrative appeal of an informal review decision under this subsection, the department bears the burden of proving a violation of law or rule by a preponderance of the evidence. If the department proves that existing and available records of goods or services are defective, the department may impose the a fee or sanction of, including total recoupment. Total recoupment for defective records is warranted only when the provider has failed to demonstrate by a preponderance of the evidence that the disputed goods or services were medically necessary, MaineCare-covered goods or services and were actually provided to eligible MaineCare members.
Effective July 30, 2004, unless otherwise indicated.
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