J-04_ProviderBankruptcyChecklist.doc

RFP-CMS-2007-0013

Part A Provider Overpayment Referral Checklist (CMS Pub. 100-6, Section 140)

Referrals will not be accepted without a copy of the 855 Intermediary Name:

Date Prepared:

Intermediary No. that OP is reported under on POR:

Intermediary No. that OP is reported under on Accounts Receivable Report (751):

I.

Provider & Overpayment Information (All information that has corresponding field on Provider Overpayment Report (POR) must agree with POR. Discrepancies should be immediately resolved rather than the form delayed.)

A.

Provider Name:

B.

Provider No.:

C.

Cost Report Period:

D.

Responsible Individual(s) (Most Current) Name:

Title:

Address:

City, State, Zip:

Telephone:

E.

Overpayment Information (List information for each outstanding overpayment)

**Original Amount:

**Interest Assessed:

/Rate

*Principal Recouped:

*Interest Recouped:

Principal Referred

Interest Referred Through Date:

F.

Overpayment Type:

G.

Determination Date:

H. Intermediary Control #:

(NOTE: If un-filed cost report is the overpayment type, indicate the date un-filed cost report is (was) due to be filed, as well as the interim payments)

*Attach detailed information with case regarding recoupments, include dates applied.

**Include copies of the Master screen from the POR, for both principal and interest.

Part A Provider Overpayment Referral Checklist

II.

Accounts Receivable Reporting

(All information reported in I.E. must reconcile with amounts reported on the Accounts Receivable Report (H751))(N/A is not acceptable)

Line

Amount

A.

HI Principal Reported on H751 Part A as transferred to RO

Line Reported on

HI Interest Reported on H751 Part A as transferred to RO

SMI Principal Reported on H751 Part B as transferred to RO

SMI Interest Reported on H751 Part B as transferred to RO

Total

B.

Indicate quarter information was reported on the H751:

III. Collection Efforts

(For items III A-C, unless there is a post-petition demand letter, this information would not be relevant to recovering in bankruptcy).

A.

Include copies of the First, Second and Third demand letters (Ref. CMS Pub. 13-2, Sec. 2222). If full series of letters was not sent, explain why.

B.

Include copies of all correspondence, telephone contacts, etc. pertinent to this transfer.

C.

List additional actions you have taken to recoup overpayment and include copies of all; (e.g., attempts to locate through directory assistance, AMA, post office forwarding addresses; disconnected phones, flags against other legal entities

D.

The contractor must establish whether or not a particular provider is participating in the Medicaid Program so that the Federal Share of Medicaid payments can be withheld, if appropriate, in accordance with CMS Pub. 13-2, Sec. 2226ff.

PARTICIPATING:

Yes No ____ Medicaid Number/State: ______________________________________________

(If Yes, Medicaid # and State must be included)

E.

Is the provider listed in the Fraud Investigation Data Base? (FID) Yes No ____ Part A Provider Overpayment Referral Checklist IV. Ownership Check the appropriate ownership affiliation:

A.

INCORPORATED

EIN # _____________________

Chain Organization Yes

If yes, who is the home office Intermediary?

Incorporation Date ________________

B.

PARTNERSHIP

EIN # _____________________

1) If partnership, list names and SS#s of all partners. 2) If Corporation, list names and addresses of officers. 3) If Chain organization, list other provider names, addresses, and provider numbers.

C.

Is "Responsible Individual(s)" information the most current? Yes

Provide alternate contact(s), Name, Title, Address and Telephone Number:

D.

Are claims for services still being submitted?

Yes

If yes, why is referral being made? _____________________________________________ _________________________________________________________________________

E.

Has there been a change of ownership?

Yes No ____

If yes, what is the date? ____/____/_______ Has the new owner assumed the previous owner's provider agreement? Yes No ____ (Provide copy of sales agreement.)

F.

Has recoupment from new owner been attempted?

Part A Provider Overpayment Referral Checklist V.

General

A.

Is the provider still participating in the Medicare program? Yes No ____ Note:

If the provider is still participating in the program and claims recoupments are being made, do not transfer case to the RO.

B.

Are you aware of any bankruptcy proceedings planned or commenced on behalf of the provider transferred?

Yes No ____

Copies of pertinent court documents should be submitted. Take the following program safeguard actions when a bankruptcy situation is identified:

· Adjust interim payment calculation to ensure that no overpayment is made

· Consult the CMS RO before applying any disposition regarding cost report underpayments

· Expedite cost report desk reviews and audit settlements

· Tentative settlements should not be made in bankruptcy cases

· Consult the CMS RO regarding any cost reports pending submission and the expected dates of submission

C.

Did the provider request an extended repayment schedule (ERS)? Yes No ____ If yes, was it approved? Yes No ____ Length of ERS __________________ Number of payments made Attach any financial documentation submitted.

D. Did provider request an intermediary or PRRB hearing? Yes No ____ If yes, do not transfer unless the decisions have been rendered. Submit all pertinent information.

Cases pending a Reopening, Bankruptcy, BCA Review, or PRRB Decision, should not be transferred to the CMS-RO until judgment has been rendered. Copies of all decisions must be included.

INSTRUCTIONS: If you do not provide any requested information, you must give a detailed explanation of why you cannot secure the information. We will return incomplete forms with the entire case.

Signature:

Telephone:

Date:

INTEREST/RECOUPMENT COMPUTATION

PROVIDER NAME:

PROVIDER NUMBER: ______________________________________

OVERPAYMENT AMOUNT:

INITIAL DEMAND LETTER DATE: _______________________

INTEREST RATE: %

COST REPORT PERIOD: _________________________________

Payment Date Period (30 Days) Interest Charges Recouped Amounts Applied to Interest Interest Balance Applied to Principal Principal Balance

Part B Physician/Supplier Overpayment Referral Checklist (CMS Pub. 14-3, Section 7142.2) Referrals will not be accepted without a copy of the 855

Carrier Name

Date Prepared:

Carrier No. that OP is reported under on PSOR

Carrier No. that OP is reported under on Accounts Receivable Report (751)

I.

Physician/Supplier Overpayment Information

(All information that has corresponding field on Physician Supplier Overpayment Report (PSOR) must agree with PSOR)

Phy/Supp. Name

B.

Phy/Supp No.

UPIN: _____________________

C.

Responsible Individual(s)

Title: ______________________________ Address:

City, State, Zip:

Telephone: __________________________

Overpayment Information

**Original Amount: ___ **Interest Assessed : /Rate

*Principal Recouped:

*Interest Recouped: _____________ Principal Referred:

Interest Referred: _____________

Through date: ____/____/_______ Query if overpayment is based on fraud.

*Attach detailed information with case regarding recoupments, include dates applied.

**Include a copy of the Master screen from the PSOR.

Information requested in E though L is needed for all claims involved in overpayment.

E.

Discovery Date: ____/____/_____

F.

Determination Date: ____/____/_______ G.

DCN:

H.

Cause of OP: ________________________ I.

Claim Number J.

Claim Paid Date: ____/____/_______ K.

Beneficiary Name:

L.

HI Claim No:

Part B Physician/Supplier Overpayment Referral Checklist

II.

Accounts Receivable Reporting

(All information reported in I.D. must reconcile with amounts reported on the Accounts Receivable Report (H751)) (N/A is not acceptable)

Line

Amount

A. SMI Principal Reported on H751 Part B as transferred to RO

SMI Interest Reported on H751 Part B as transferred to RO

Indicate quarter information was reported on the H751

Is this Overpayment reported on the M751?

Yes No ____ III. Collection Efforts

A.

Include copies of the First and Second demand letters (Ref. CMS Pub. 14-3, Sec. 7142). If full series of letters was not sent, explain why.

Include copies of all correspondence, telephone contacts, etc. pertinent to this transfer.

List additional actions you have taken to recoup overpayment and include copies of all, (e.g., attempts to locate through directory assistance, AMA, post office forwarding addresses; disconnected phones, flags against other numbers).

The Carrier must establish whether or not a particular provider is participating in the Medicaid program so that the Federal Share of Medicaid payments can be withheld, if appropriate, in accordance with CMS Pub. 14-3, Sec. 7170.1.

PARTICIPATING:

Medicaid Number/State: ___________________________________________

(If Yes, Medicaid # and State must be included)

Part B Physician/Supplier Overpayment Referral Checklist IV. Ownership Check the appropriate ownership affiliation:

INDIVIDUAL

Tax ID #

SS #

INCORPORATED

Chain Organization? Yes No____

Incorporation Date

TIN # ___

PARTNERSHIP

TIN # _____________________

Is A Responsible Individual(s) information the most current? Yes No ____ Provide alternate contact(s), Name, Title, Address and Telephone Number

E.

Is recovery due from the beneficiary or other 3rd party payor?

Yes No ____ If yes, why was recovery not made (enclose copies of letters and replies).

F.

Are claims for services still being submitted?

Yes No ____ If yes, why is referral being made?

G.

Are claims for services/supplies being submitted under another physician/supplier number?

If Yes, provide alternate number______________________ Is the tax identification, or social security number the same as debtor's? If yes, recoupment should be attempted.

H.

Has there been a change of ownership?

Yes No ____ If Yes, Has the new owner assumed any of the previous owner's liabilities?

Yes No ____ (Provide copy of sales agreement.)

Part B Physician/Supplier Overpayment Referral Checklist

V.

General

A.

Is the physician/supplier still participating in the Medicare program? Yes No ____ B.

Are you aware of any bankruptcy proceedings planned or commenced on behalf of the provider transferred?

Yes No ____ Please provide copies of pertinent court documents.

Did the physician/supplier request an extended repayment schedule (ERS)?

If yes, was it approved?

Yes No ____ Length of ERS ____________ Number of payments made _________ Attach any financial documentation submitted.

Did the physician/supplier request a Fair Hearing or ALJ Hearing?

If yes, do not transfer unless the both fair hearing and ALJ decisions have been rendered. Submit all pertinent documentation.

THIS FORM MUST BE COMPLETE. IF ANY REQUESTED INFORMATION IS NOT PROVIDED, A DETAILED EXPLANATION MUST BE GIVEN AS TO WHY THE INFORMATION CANNOT BE SECURED. INCOMPLETE FORMS WILL BE RETURNED WITH THE ENTIRE CASE.

Signature:

Telephone:

Date:

Interest/Recoupment Computation

PROVIDER NAME:

PROVIDER NUMBER:

OVERPAYMENT AMOUNT:

INITIAL DEMAND LETTER DATE:

INTEREST RATE: %

CLAIM NUMBER:

Payment Date Period (30 Days) Interest Charges Recouped Amounts Applied to Interest Interest Balance Applied to Principal Principal Balance

Attachment B Contractor Bankruptcy Checklist

Send the following information to the RO upon learning that a provider has or may soon file for bankruptcy:

Attachment J-4