(1) This section applies to provider overpayment disputes with providers who furnish health care services to Washington apple health clients, except those overpayment disputes to which chapter
182-502A WAC applies. For the purposes of this section:
(a) "Agency" means the health care authority and its designees.
(b) "Provider" has the same meaning as vendor in RCW
41.05A.010(5).
(2) If the medicaid agency determines that a provider was overpaid, the agency may take any of the following actions:
(a) Review claims, encounters, or payments;
(b) Refer the provider to the agency's office of program integrity;
(c) Refer the provider to the Washington state medicaid fraud control unit;
(d) Refer the provider to the appropriate state health care professional discipline authority;
(e) Terminate the provider's participation in Washington apple health;
(f) Assess a civil penalty against the provider, per RCW
74.09.210;
(g) In the event of a prepay review, suspend some or all payments;
(h) Adjust or void an improper claim, encounter, or payment;
(i) Recover any moneys that the provider received as a result of overpayments as authorized under chapter
41.05A RCW; and
(j) Any other action authorized by Title 182 WAC.
(3) A provider may contest an overpayment by requesting a hearing.
(4) The hearing request must:
(a) Be in writing;
(b) Identify each overpayment being contested;
(c) State each reason why the provider thinks the overpayment is incorrect;
(d) Include documentation to support the provider's position; and
(e) Include a copy of the overpayment notice.
(5) The hearing request must be served on the agency at the address specified in the overpayment notice, in a manner which provides proof of receipt, no later than twenty-eight calendar days after the provider received the overpayment notice.
(6) The hearing is conducted under the Administrative Procedure Act and chapter
182-526 WAC.
[Statutory Authority: RCW
41.05.021 and
41.05.160. WSR 15-01-056, § 182-502-0230, filed 12/10/14, effective 1/10/15. WSR 11-14-075, recodified as § 182-502-0230, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW
74.08.090,
74.09.080, and
74.09.290. WSR 11-11-017, § 388-502-0230, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW
74.08.090,
74.09.520,
34.05.020,
34.05.220. WSR 00-22-017, § 388-502-0230, filed 10/20/00, effective 11/20/00. Statutory Authority: RCW
74.08.090. WSR 94-10-065 (Order 3732), § 388-502-0230, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-042.]