News
23-972m Reminder: Medi-Cal Overpayment to Providers Must Be Recovered and Returned
Date: 09/01/23
Providers must report and return any overpayment within 60 calendar days
An overpayment is any payment made to participating physicians and other providers by California Health & Wellness Plan (CHWP) to which the participating physicians and other providers are not entitled to receive.
On May 8, 2023, the Department of Health Care Services (DHCS) issued All-Plan Letter (APL) 23-011 (PDF) to provide guidance and clarification to Medi-Cal managed care health plans (MCPs) regarding the recovery of all overpayments to physicians and other providers. The APL provides additional clarification on provider-identified overpayment reporting requirements.
The policy described in this update applies to all overpayments from CHWP to participating physicians and other providers, and recoveries of overpayments by CHWP.
Recoveries retained under the False Claims Act cases, or through other investigations by the DHCS, California Department of Justice, Centers for Medicare & Medicaid Services, or any other duly authorized law enforcement or investigatory agency, are not subject to this policy.
Provider-identified overpayment reporting requirements
CHWP requires, and has a mechanism for, participating physicians and other providers to:
- Report to CHWP when they have identified that they have received an overpayment,
- To return the overpayment to CHWP within 60 calendar days after the date on which the overpayment was identified, and
- To notify CHWP in writing of the reason for the overpayment.
This section does not address a situation where CHWP identifies an overpayment and notifies the institutional or professional provider. In this case, CHWP will follow the requirements outlined in Health and Safety Code section 1371.1.
How to report a provider-identified overpayment
If a physician or other provider is aware of receiving an overpayment made by CHWP, the physician or other provider must promptly refund the overpayment amount with a copy of the applicable Remittance Advice and a cover letter indicating why the amount is being returned. Send the overpayment refund and applicable details to the CHWP Overpayment Recovery Department at:
Medi-Cal CSC, Provider Claims Appeals Unit
P.O. Box 610
Rancho Cordova, CA, 95741-0610
Providers can access CHWP’s policy and procedure on overpayments in the Provider Manual > Provider Manual / Billing Manual (PDF).
For more information
Review the complete details of APL 23-011 (PDF).
Additional information
Providers are encouraged to access CHWP’s provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CHWP at 877-658-0305.
This information applies to Physicians, Independent Practice Associations (IPAs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.