DME and FTC Recovery Project

Meridian Medicaid has conducted a claims system quality audit to ensure compliance with state limits and accurate payment processing. As a result of these audits, a recovery project has been initiated to address overpayments related to Durable Medical Equipment (DME) Limits and Duplicate First-Time Claim (FTC) Recoveries.

We want to ensure you understand the reason for this recovery project, how it may impact your claims, and what steps you can take.

Why Did I Receive a Notice of Recoupment?

DME Claims Recovery:

Meridian Medicaid performed a claims system quality audit related to DME State Limits. During this audit Meridian identified that our claims processing system required corrections to the DME limits to align with the Michigan Department of Health and Human Service (MDHHS) Community Health Automated Medicaid Processing System (CHAMPS) and the Centers for Medicare & Medicaid Service (CMS) Medicaid National Correct Coding Initiative (NCCI). Once the system was corrected for accuracy, Meridian commissioned a recovery project limited to the last 365 days impacting 519 DME NPIs for claims that paid over CHAMPS/NCCI Medicaid Limits.

When performing this type of payment recovery, Meridian sends a 60-day advance notice which allows the providers to dispute the recoupment.

Upon completion of the notification period, we adjust the claim against the system’s corrected limits to ensure accurate processing. This could result in claim payment recoupment (dollar amount paid over the limit only). The claim, when adjusted, would also consider authorizations approved over the limits to align with authorization approval and ensure the pay claims according to authorization. Meridian has extended the notice period by an additional 30 days so we can work individually with provider partners if they feel that a claim identified for adjustment to pay according to state limits incorrectly (i.e. the provider believes the claim is paying according to CHAMPS/NCCI Medicaid documented limits)¹

What action should I take as a Provider if I received this DME Claims Recovery notice?

• Review the applicable claims specified in the notice. These claims were identified per Meridian’s analysis as paying over MDHHS documented limits.
• If you believe that the claim was not billed or paid over the state limits, then submit that claim number via our Web Portal where our Issue Management Taskforce will review your claims to see if we should remove them from the recovery. You can provide multiple claim numbers on a single claim form for review. If you would like to request a meeting to discuss your concerns directly, please request that on the form along with your contact information and we will reach out to schedule a meeting.
  • TIP: If the applicable claim previously received authorization over the state limit, the system will recognize the authorization when we reset/adjust the claim to pay against the updated, now accurate, system logic. You will get a secondary Explanation of Payment (EOP) if the claim remains in this recovery project, but there should be no change in the payment amount if the claim previously paid accurately. If you would prefer to not receive a secondary EOP to avoid potential confusion to billing offices (since there will be no change in payment/processing), you can still request the claim is removed from the project if you have approved authorization on file for the claim.

Duplicate First Time Claim (FTC) Payment Recovery:

After an investigation into low encounter acceptance rates, Meridian Medicaid performed a claims system quality audit, which identified the root cause as duplicate FTC (First Time Claim) submissions. During this audit Meridian identified that our claims system was not configured to identify duplicates, allowing payment/denial on multiple FTCs. Programming logic to identify duplicate FTCs was introduced in Q3 of 2024 and a recovery project was created going back to the last 365 days of processing to recover the duplicate payments, and to ensure there is a single FTC submitted to Meridian and encountered to the state. When performing a recovery of this nature, Meridian sends a 60-day advance notice which allows the providers to dispute the recoupment.

Upon completion of the notification period, we adjust the claim against the system’s configuration to ensure accurate processing (i.e. that a single claim is supporting the services billed).

Meridian has monthly training webinars available upon request to make sure providers understand what to do if they get a claim denial or underpayment and next steps to resolve the issue; either a formal appeal process if the provider does not plan to make adjustments to how the claim is billed or the documentation provided, or submission of a corrected claim (not an FTC) if the provider is adjusting billing and/or providing requested medical documentation.

What action should I take as a Provider if I received this FTC Duplicate notice?

• Review the claims identified in the notice. These claims were identified per Meridian’s analysis as having another FTC on file for the member, with services billed and date of service submitted on which processing and payment has already occurred. The claim selected for recovery has been identified as the duplicate FTC.
• If you believe that the claim was not billed/processed under a different claim number for the services provided then please submit that claim number via our Web Portal where our Issue Management Taskforce will review your claims to see if we should remove them from the recovery and/or adjust our processing methodology to not identify the scenario moving forward. You can provide multiple claim numbers on a single claim form for review. If you would like to request a meeting to discuss your concerns directly, please request that on the form along with your contact information and we will reach out to schedule a meeting.
• We also offer supplemental training via request through our intake form to go over how to submit appeals and corrected claims to ensure that our billing offices know how to avoid these duplicate FTC recoveries.

Tips for understanding if you have a duplicate claim with Meridian:

• After you submit an First Time Claim (FTC) you should receive your Explanation of Payment (EOP) from Meridian within 30 days of submission
• If you disagree with the payment decision as outlined in the EOP, you have the following processes to support you:
  • You can submit a reclassed/corrected claim. This means you, the provider are changing something about your original submission to obtain a different outcome in processing. Examples include: submission of requested medical documentation, revisions to provider specialty detail or place of service etc. on the claim form. Reclassed claims only qualify for claim adjustment if something has changed in the submission.
  • You can submit an appeal. This means you, the provider are not changing the way you billed, documentation provided, etc. You believe that the claim should reimburse differently than the EOP with no change on your behalf, due to an error in processing. An appeal is also the most efficient course of action if you have a claim denial related to prior authorization.
  • If your appeal is not successful or your reconsideration does not lead to the expected outcomes, and you still feel that you need guidance or clarity, you can submit a Provider Relations Web Form Inquiry with the applicable claim number and an explanation of your concern, and a Meridian Claims Subject Matter Expert will reach out for additional support.
  • Please note: When you submit a reclassed/corrected claim you will receive an updated claim number or “document control number” as outlined below. This can be an easy way to understand why the system would have flagged a claim as a “duplicate” FTC instead of a reclassed/corrected submission as required.

[1] Meridian’s claims system configuration uses CHAMPS DME limits as the primary source of truth. If MDHHS/CHAMPS have no stated limits, we are to use NCCI Medicaid DME limits. If both CHAMPS and NCCI Medicaid have no stated limits, then there is no limit. This aligns to our State Contract requirements/FFS processing.