Credit Balance Self-Review

Credit Balance Self-Reviews – Coordinated by the Recovery Audit Contractor (RAC)

The Department of Human Services (department), Bureau of Program Integrity (bureau) is working with HMS (the Commonwealth’s RAC vendor) to coordinate provider credit balance self-reviews. The department encourages all provider types to routinely assess their billing and record keeping practices and voluntarily come forward and disclose any overpayments of Medical Assistance (MA) funds.

The objective of the credit balance self-review is to identify payments made to providers that should not have been made or were received from other commercial health insurers, governmental health insurers, and/or other third party payers.

The self-review should be conducted every quarter and will require a review of your billing records to identify credit balance accounts that have been overpaid by MA. Letters will be sent to providers with instructions and requirements for the self-review.

The RAC will monitor responses and, at the direction of the bureau, select providers for a comprehensive on-site credit balance audit. Selection criteria for on-site audits may include, but are not limited to: lack of response, lower than expected response, untimely response for a quarterly self-review period, data mining results, or time period from last on-site review.

The department recognizes that self-reviews provide viable opportunities for disclosure. The department is committed to promoting an environment of openness and cooperation.

Credit Balance Self-Review Worksheet