388-71-0546  <<  388-71-0548 >>   388-71-0551

WAC 388-71-0548

When is an individual provider subject to an overpayment?

(1) Unless payment is otherwise required by state or federal law, it is an overpayment as defined in RCW 43.20B.010 and 41.05A.170 if an individual provider (IP) is paid by the department and:
(a) Did not actually perform the work;
(b) Payment is for dates of service after the death of the client;
(c) Payment is for services provided when the client was admitted to a hospital, nursing home, or other institutional setting;
(d) Payment is for dates of service when the client was outside of the United States;
(e) Did not have a valid IP services contract at the time the services were provided and had been notified by the department to stop the provision of services;
(f) Had not completed required training or obtained required certification at the time the services were provided and had been notified by the department to stop the provision of services;
(g) Had a disqualifying crime or negative action at the time the services were provided and had been notified by the department to stop the provision of services;
(h) Provided services after being notified by the department to stop the provision of services;
(i) Provided services that are not included in the client's plan of care;
(j) Provided services that exceeded the amount of the client's benefit in the client's plan of care where those services were not necessitated by an emergent and immediate need of the client and the IP is not a family member or household member of the client; or
(k) Received erroneous or duplicate payment(s).
(2) If the department determines an IP was overpaid, even if it was due to department error, the department recovers any moneys that the IP received as a result of overpayments, as authorized under chapter 41.05A RCW or 43.20B RCW.
(a) The department will send the IP notice of the overpayment.
(b) The IP has a right to request an administrative hearing when notice of an overpayment is received from the department.
(c) To request an administrative hearing, an IP must send a written request to the office of financial recovery within twenty-eight days of the IP's receipt of notice of the overpayment that:
(i) States the basis for contesting the overpayment notice;
(ii) Includes a copy of the department's notice with the request; and
(iii) Is sent by certified mail return receipt requested (CMRRR) or another trackable delivery service.
(d) The appeal process will be governed by the Administrative Procedure Act (chapter 34.05 RCW).
[Statutory Authority: RCW 43.20B.675, 74.09.220, 74.09.290, and 74.09.520. WSR 19-05-008, § 388-71-0548, filed 2/7/19, effective 3/10/19.]
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