Common use of Contractor Recoupment from Enrollee for Fraud Clause in Contracts

Contractor Recoupment from Enrollee for Fraud. Waste and Abuse If permitted by state and federal law, the Contractor shall request a refund from the Enrollee for all paid Claims in the event the Department has established that the Enrollee was not eligible to be enrolled through an administrative determination or adjudication of Fraud. The Contractor shall, upon receipt of a completed OIG investigation of a Contractor’s Enrollee that calls for administrative recoupment, send a request letter to Enrollee seeking voluntary repayment of all Claims paid by the Contractor on behalf of Enrollee during time period Enrollee was found to be ineligible to receive services. The request letter shall include the following as provided by the Department: the reason for the Enrollee’s ineligibility, time period of ineligibility, and amount paid during the period of ineligibility. The Contractor shall report, on a monthly basis, to the Commonwealth any monies collected from administrative request letters during the previous month and provide a listing of all administrative request letters sent to Enrollees(s) during the previous month. The Contractor is only required to mail the initial letter to the Enrollee requesting repayment of funds and accept repayment on behalf of the Department. The Contractor is not required to address any due process issues should those arise. The Contractor shall work with Department’s agent to obtain monies collected through court ordered payments. Any outstanding payments not collected within six (6) months shall be subject to be collected by the Commonwealth and shall be maintained by the Commonwealth. The foregoing provisions shall be construed to require Contractor’s reasonable cooperation with the Commonwealth in its efforts to recover payments made on behalf of ineligible persons, and shall not create any liability on the part of the Contractor to reimburse amounts paid due to Fraud that the Contractor has been unable to recover.

Contractor Recoupment from Enrollee for Fraud. Waste Xxxxx and Abuse If permitted by state and federal law, the Contractor shall request a refund from the Enrollee for all paid Claims in the event the Department has established that the Enrollee was not eligible to be enrolled through an administrative determination or adjudication of Fraud. The Contractor shall, upon receipt of a completed OIG investigation of a Contractor’s Enrollee that calls for administrative recoupment, send a request letter to Enrollee seeking voluntary repayment of all Claims paid by the Contractor on behalf of Enrollee during time period Enrollee was found to be ineligible to receive services. The request letter shall include the following as provided by the Department: the reason for the Enrollee’s ineligibility, time period of ineligibility, and amount paid during the period of ineligibility. The Contractor shall report, on a monthly basis, to the Commonwealth any monies collected from administrative request letters during the previous month and provide a listing of all administrative request letters sent to Enrollees(s) during the previous month. The Contractor is only required to mail the initial letter to the Enrollee requesting repayment of funds and accept repayment on behalf of the Department. The Contractor is not required to address any due process issues should those arise. The Contractor shall work with Department’s agent to obtain monies collected through court ordered payments. Any outstanding payments not collected within six (6) months shall be subject to be collected by the Commonwealth and shall be maintained by the Commonwealth. The foregoing provisions shall be construed to require Contractor’s reasonable cooperation with the Commonwealth in its efforts to recover payments made on behalf of ineligible persons, and shall not create any liability on the part of the Contractor to reimburse amounts paid due to Fraud that the Contractor has been unable to recover.