Refund Recovery Policy
It is Utilization Review’s policy to pursue reimbursement for claims that SBCPHD has paid to providers through the MIA Program, Tobacco Settlement Funds or other programs if the patient is found to have another payer or source of payment, has become retroactively eligible for another program or if there has been a billing or payment error made by the provider or by the UR department, which requires recovery of funds.
According to the MediCal Provider Manual, Part 1– Medi-Cal Program and Eligibility, Provider Regulation, the California Welfare and Institutions Code, Section 14019.3, states that a recipient, or any person on behalf of a recipient, who has paid for health services otherwise covered by Medi-Cal and received by the recipient, is entitled to a return of any part of the payment from the provider. MediCal Provider Manual (see page 15).
- UR will send providers a spreadsheet and/or a separate letter requesting refunds for patients who have become Medi-Cal eligible or who have been found to have another source of payment or for billing or payment errors.
- For patients initially deemed eligible for Medi-Cal on a date which is over a year from the current date, UR will obtain Medi-Cal Letters of Authorization (MC-180’s) for providers for dates of service which are over one year old. UR will assist the provider in the refund process using these Letters of Authorization.
- Refunds related to errors or because the patient was found to have private insurance are expected to be reimbursed within 60 days.
- Refunds requested because the patient has become Medi-Cal or Medicare eligible are expected to be reimbursed within 90 to120 days unless an extension is requested.
- In the case that the provider does not reimburse UR within the 120 day period UR will recoup the money by offsetting current claims. Claims used to offset refunds will exclude those of patients who are pending Medi-Cal or are found to have other payer sources.
- The request for refund may be forgiven by the UR Manager in the case that the provider sends a copy of the denial letter from CenCal, Medi-Cal, and/or Medicare with the request for refund. If the reason for denial can be appealed, the UR Manager or Program Administrator will assist the provider in appealing the denial if necessary.
Please send refunds, denials, extension requests and other correspondence to:
SBCPHD Utilization Review
300 N. San Antonio Road
Room B 100
Santa Barbara, CA 93110
For questions regarding refund requests:
Phone: (805) 681-5390
FAX: (805) 681-5424