Welcome to the Department of Health Care Services Welcome to Medi-Cal Welcome to the Department of Health Care Services

HIPAA: Voluntary Disclosure Process to Refund Overpayment of 837I Electronic Claims

February 11, 2013

The Share of Cost (SOC) was not deducted from some 837I institutional electronic claims submitted in July and August 2012.

Providers were instructed to void these claims and resubmit them in the correct format, using the HI value information segment in loop 2300 of the 005010X223A2 with a qualifier of BE and value code of FC to report SOC information.

Alternatively, providers may use the voluntary disclosure process to refund these overpayments. If adopting this option, providers must have documentation showing the overpayment. The supporting documentation must be submitted as a report with the following details:

  • Recipient’s name
  • Recipient’s Medi-Cal identification number
  • Claims control number
  • Dates of services
  • Total charges
  • SOC amount
  • Noncovered services amount
  • Overpaid SOC

The total amount of money in the report should match the amount on the check submitted to the Third Party Liability and Recovery Division (TPLRD).

Mail remittance of overpayment to TPLRD at the following address:

DHCS/Overpayment Unit
MS 4720
P.O. Box 997421
Sacramento, CA 95899-7421

The check must indicate that it is for a SOC Self–Audit. Providers must mail payment by May 15, 2013, to participate in the voluntary disclosure process.

Do not send the overpayment report of patients to TPLRD. The report and a copy of the cancelled check should be maintained by the facility or by the facility's representative and presented to Financial Audit Branch personnel during the facility's cost report audit.

Direct any questions to TPLRD Overpayments Chief Marina Vinogradovat (916) 650-6559.