LD 1695
pg. 2
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LR 2641
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C.__For the purposes of this subsection, "overpayment" does
not include an overestimate made as part of a prospective
interim payment, a 3rd-party liability recovery, a
departmental administrative error or receivership fees or
debt.__In addition, this subsection does not apply to routine
adjustments of $2,500 or less that result from claims editing
or processing.

 
Sec. 2. 22 MRSA §42, sub-§7, ¶H, as enacted by PL 2003, c. 419, §2, is
amended to read:

 
H. In an administrative appeal of an informal review decision under this
subsection, the department bears the burden of proving a violation of law
or rule by a preponderance of the evidence. If the department proves
that existing and available records of goods or services are defective,
the department may impose the a fee or sanction of, including total
recoupment.__Total recoupment for defective records is warranted only
when the provider has failed to demonstrate by a preponderance of the
evidence that the disputed goods or services were medically necessary,
MaineCare-covered goods or services and were actually provided to
eligible MaineCare members.


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