1. (A) Overpayments include, but are not limited to, payments to a provider

   1. (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. (2) for services that were not payable under MassHealth on the date of service, including 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. (3) in excess of the maximum amount properly payable for the service provided, to the extent of such excess;
   4. (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;

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth

1. 2. Administrative Regulations 2-33

Provider Manual Series

Transmittal Letter Date

All Provider Manuals

ALL-227 10/01/18

1. (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;
2. (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;
3. (7) for services billed that result in a duplicate payment; or
4. (8) in an amount that a federal or state agency (other than the MassHealth agency) has determined to be an overpayment.

1. (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.