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Library: Policy

340:105-7-6. Overpayments and underpayments

Revised 3-1-98

(a) Determinations.  An overpayment occurs and is established against an adult day services client or vendor when it is discovered that a payment(s) has been made on behalf of a client to which he or she is not entitled. The overpayment must also have a determination made as to whether the client or vendor met his or her responsibilities in accordance with the adult day services policies and procedures. When it is determined that an overpayment exists, a determination of due diligence must be made in accordance with (1) - (5) of this subsection. A determination of due diligence is made to determine whether:

(1) a periodic redetermination of eligibility was completed within the time limits set by the Department and a decision made at the next possible effective date.

(2) a decision regarding case action was completed within ten days after the information was obtained indicating a change in the client’s circumstances.

(3) the case record contains a signed application, Adult Day Services Referral/Application Form, which advises the client of his or her reporting responsibilities.

(4) the adult day services vendor was notified of any change affecting the authorization of day services, including co-payment changes, on behalf of a client and that the case record reflects prompt notification.

(5) the vendor was kept abreast of Department policy regarding rates, claims procedures, and daily attendance recording.

(b) Client error.  It is the responsibility of the client, when the Department has informed him or her of the conditions of eligibility which must be met, to notify the county office within ten days of any change in his or her circumstances to include income, address, phone number, and authorized representative.  Failure of the client to report changes may result in an overpayment.

(c) Vendor error.  When the Department has authorized payments on behalf of the client and notified the vendor of any applicable co-payments, it is the responsibility of the adult day services vendor to submit accurate and correct day services claims in accordance with the authorization.  The vendor claims only after the provision of the adult day services and deducts any co-payments as authorized.

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