County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Subject Overpayments Number Page 1602 1 of 2 Issue Date 3102015 Effective Date Upon Receipt Background This section provides regulations regarding identifying and computing potential overpayments referring potential overpayments to the Department of Health Care Services DHCS Investigations Branch Policy 1 Definition of potential overpayment There is a potential overpayment when A beneficiary is over property for an entire month A competent beneficiary or key person provided incorrect information or failed to report within 10 days any change in information that affects eligibility or would cause an increased SOC A beneficiary fails to report other health coverage There is no potential overpayment in the following situations Administrative error caused the ineligibility or understated SOC The change was reported within 10 days but the change could not be made until the following month due to timely Notice of Action NOA requirements The change is reported more than 10 days after the change has occurred but the worker can send a change NOA timely The change has no impact on the eligibility or SOC in that month The beneficiary or key person was not informed of their reporting responsibilities The worker completed the statement of facts using diligent search procedures and later discovers information that would cause ineligibility or understated SOC The beneficiary becomes incompetent at the time of the change or during the 10 day reporting period If competency is questionable the worker must treat the ineligibility or understated SOC as a potential overpayment The key person has no knowledge of income or resources 2 Potential vs Actual Amount The actual amount of the overpayment is unknown until the actual amount of MediCal benefits used is determined by DHCS County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Subject Overpayments Number Page 1602 2 of 2 3 When to refer to DHCS investigations Refer potential overpayments to DHCS Investigations when the potential overpayment amount is over 10000 Do not refer to DHCS if the potential overpayment SOC excess property ineligibility and wages is estimated to be under 10000 When the potential overpayment for the entire period will obviously be under 10000 note in the case file and take no further action 4 Documentation Document all decisions regarding potential overpayment actions in the case file including the reasons for evaluating a potential overpayment referring the overpayment to DHCS or not referring to DHCS Procedure The following procedures can be found in the MediCal Overpayment Processing Guide Worker responsibilities for calculating overpayments How to calculate a potential overpayment Completing referrals to DHCS Investigations Impacts MediCal References MEM 50783 MEM 21M1 21M8 MEM 50781 MEM 50786 MEM 50163 ACWDL 0138 ACWDL 0020 ACWDL 8924 Sunset Date This policy will be reviewed for continuance by 3102018