Overpayment Referral Procedures

The EW must take the following steps when referring potential MC overpayments of $100 or more to the local DHCS Investigation Unit.

Overpayment Referral Procedures

  1. EW    
    1. Discovers a potential MC overpayment.
    2. Determines the period of the potential MC overpayment.
    3. Determines the type of potential MC overpayment.
    4. Requests MC usage information from the local DHCS Investigation Unit using MC 609. Indicate the time period for the potential overpayment and the reason.
  2. DHCS Investigation Unit    
    1. Provides the requested MC usage information to the EW. The usage information will be listed by DHCS Investigation Unit on the MC 609. (This may take 3 to 5 weeks.)
  3. EW    
    1. If there is usage of $100 or more, (based on the MC usage information received on the MC 609) takes the following action:
      1. Redetermines MC eligibility and/or SOC for each month with usage.
      2. Completes the MC 224 A or MC 224 B, as appropriate, to determine the potential overpayment amount.
      3. Fax the referral to DHCS Investigation Unit [Fax Number (916) 440-5343].
      4. No further action is required by the EW.
  4. DHCS Investigation Unit    
    1. Investigates the referral and take the appropriate action.

Where to Send Referrals

All overpayments of $100 or more will be referred directly to the local DHCS Investigation Unit except for unreported other health coverage (OHC) which should be referred to the DHCS, Health Insurance Section.

Required Forms For Overpayment Referral Packets

The following forms are included in the Overpayment referral packet:

Form Number and Name

Instructions

MC 609 “Confidential Medi-Cal Complaint Report”
  • Complete this form for ALL potential MC overpayments or fraud.
  • Send the original to DHCS Investigation Unit.
  • Scan a copy into the Imaging system.

MC 224 A “Medi-Cal Potential Overpayment Reporting Worksheet

- Income Or Other Health Coverage”
  • Complete this form for potential MC overpayments of $100 or more which are due to an increase in income or change in circumstances which affects the client’s SOC or unreported other health coverage (OHC).
  • Send the original and 1 copy to DHCS Investigation Unit.
  • Scan a copy via Imaging.

MC 224 B “Medi-Cal Potential Overpayment Reporting Worksheet

- Property”
  • Complete this form for potential overpayments of $100 or more when a change in property affects eligibility or a change results in total ineligibility of one or more persons in the case.
  • Scan a copy via Imaging.

NOTE: If the EW is unable to establish an exact overpayment period, or potential overpayment amount, complete the MC 224 A/B with all the available information.

“Statement of Facts” (SSApp, SOF from CalSAWS, or SAWS 2 Plus) & Supplemental forms
  • Send one photocopy of the Statement of Facts and Supplements (if any) covering the potential overpayment period.

Other forms as needed

Send one photocopy of any pertinent forms/documents covering the potential overpayment period, including but not limited to:

  • IEVS Abstract.
  • Bank Records, copies of all statements provided by the client.
  • Earnings Statements, from EDD and all of the client's pertinent earnings statements.
  • Case Narrative relating to the potential overpayment period.

Forms and Instructions for Completion

“Confidential Medi-Cal Complaint Report” (MC 609)

The EW must complete an MC 609 for ALL MC potential overpayments or fraud.

  1. Check mark “IEVS” box in red ink (if applicable).
  2. Check the appropriate box to indicate if the case is open or closed and enter the closing date, if applicable.
  3. Enter the 14 digit county case number, the name and phone number (including area code) of the EW handling the case.
  4. Enter the name, telephone number (including area code) and address of the person reporting the complaint.
  5. Enter the name, date of birth, social security number, current address and telephone number (including area code) of the MC client.
  6. Enter the name of the MC provider, (i.e., doctor, pharmacy, etc.), provider number (if known), current address and telephone number (including area code).
  7. Explain the reason for the referral and give as much information as possible. If the referral is based on a potential overpayment, list all family members affected by the potential overpayment and their social security numbers. Give the source of the income or property that caused the overpayment. If a person has been acting on behalf of the client (i.e., responsible party or conservator), list that person’s name, address and telephone number (including area code).
  8. Enter the name, date, address and telephone number (including the area code) of the person filling out the form. Enter the date the complaint is written, as it is essential in cases that may result in criminal charges.
  9. Request the usage information for the potential MC overpayment period in the “Details of Complaint” section of the MC 609.

The remainder of the form is completed by DHCS Investigation Unit’s staff.

“Medi-Cal Potential Overpayment Reporting Work Sheet - Income or Other Health Coverage” (MC 224 A)

The EW must complete an MC 224 A when there is a potential MC overpayment of $100 or more due to an increase in income or change in circumstances which affects the client’s SOC.

Section 1 - Case Information

  1. Enter the 14 digit county case number.
  2. Check the “IEVS” box in red ink (if applicable).
  3. If the case is active, enter the date the case was opened. If the case is closed, enter the date the case was closed. (Explain the reason the case was closed on the MC 609, in the “Details of Complaint” section).
  4. Enter the name, date of birth, social security number, and the period of MC eligibility of each MFBU member included in the potential MC overpayment. The EW must review the following groups of clients whether or not they must be listed on the form.
  • PREGNANT WOMAN: When there is a potential SOC overpayment which involves a pregnant woman who has two aid codes (i.e., an aid code for pregnancy-related services under the Income Disregard program and an aid code for non-pregnancy-related services with a SOC) AND the overpayment occurred ONLY under the aid for non-pregnancy related services, enter that aid code in RED. Otherwise, the DHCS Investigation Unit will consider medical services received under BOTH aid codes.
  • INFANT OR CHILD: When there is a potential SOC overpayment which involves a family member with an infant or a child who was eligible under or the Income Disregard program or Continuous Eligibility for Children (CEC,) and remains eligible, do not include the name of that infant/child with the other MFBU members who are in the potential overpayment. The DHCS Investigation Unit will determine overpayments ONLY for the MFBU members listed on the form.

Section II - Possession of Other Health Coverage

The EW must complete this section if it appears a potential MC overpayment may exist because of a change in other health coverage (OHC) due to changes in employment or marital status, or evidence of payments from workers compensation or an insurance company.

Section III - Income Overpayment Computation

  1. The EW must enter the dates of the potential MC overpayment period and the reason(s) why the SOC should have increased (i.e., increased earnings, change in family composition, etc.).
  2. Overpayment Computation

The EW must complete columns 1-6. If there are more than 12 months involved, indicate “continued” at the end of the column and list the additional information on a second sheet of paper and attach it to the MC 224 A.

Columns 7-8 will be completed by DHCS Investigation Branch.

Section IV - County Worker Comments

The EW completes this section to specify the circumstances of ineligibility. If additional space is needed, attach a separate sheet of paper and attach it to the MC 224 A.

Section V - County Worker Completing the Form

The EW must complete this section thoroughly. The name of the EW must be printed legibly. Include the area code with the phone number.

“Medi-Cal Potential Overpayment Reporting Work Sheet - Property” (MC 224 B)

The EW must complete this form for potential overpayments of $100 or more when a change in property affects eligibility or results in total ineligibility of one or more persons in the case.

Section 1 - Case Information

  1. Enter the 14 digit county case number.
  2. Check the “IEVS” box in red ink (if applicable).
  3. If the case is active, enter the date the case was opened. If the case is closed, enter the date the case was closed. (Explain the reason the case was closed on the MC 609, in the “Details of Complaint” section.)
  4. Enter the name, date of birth, Social Security number and period of MC eligibility of each MFBU member included in the potential MC overpayment.

Section II - Property

The EW must check the boxes that apply. Indicate the time period and reason for ineligibility.

Section III - Overpayment Computation

The EW must complete columns 1-8. If there are more than 12 months involved, indicate “continued” at the end of the column and list the additional information on a second sheet of paper and attach it to the MC 224 B.

Section IV - Summary

The EW completes the amount of the potential overpayment. The MC usage information and actual amount of overpayment is completed by DHCS.

Section V - County Worker Comments

The EW completes this section to specify the circumstances of ineligibility. If additional space is needed, attach a separate sheet of paper and attach it to the MC 224 B.

Section VI - County Worker Completing the Form

The EW must complete this section thoroughly. The name of the EW must be printed legibly. Include the area code with the phone number.

Related Topics

Overpayment Overview

Overpayment Rules