23-970m 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 Health Net, on behalf of CalViva Health, 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 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 the Plan to participating physicians and other providers, and recoveries of overpayments by the Plan.

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

The Plan requires and has a mechanism for participating physicians and other providers to:

• Report to the Plan when they have identified that they have received an overpayment,
• To return the overpayment to the Plan within 60 calendar days after the date on which the overpayment was identified, and
• To notify the Plan in writing of the reason for the overpayment. 

This section does not address a situation where the Plan identifies an overpayment and notifies the institutional or professional provider. In this case, the Plan 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 the Plan, 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 Plan’s Overpayment Recovery Department at:

Health Net of California, Inc.
Attention: Claims Recover Team
P.O. Box 396027
San Francisco, CA 94139-6027

Providers can access Health Net’s policy and procedure on overpayments in the Medi-Cal Provider Operations Manual, available in the Provider Library > Overpayment Procedures.

For more information

Review the complete details of APL 23-011 (PDF). 

Additional information

Providers are encouraged to access the 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 CalViva Health at 888-893-1569.

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.

This information applies to Medi-Cal in Fresno, Kings and Madera counties.