Form Mc 224 A - Medi-Cal Potential Overpayment Reporting Work Sheet Income Or Other Health Coverage
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1
2State of California—Health and Human Services Agency
Department of Health Care Services
MEDI-CAL POTENTIAL OVERPAYMENT REPORTING WORK SHEET
INCOME OR OTHER HEALTH COVERAGE
Section I—Case Information
County ID
Case status effective date(s)
IEVS
_____/_____/_____
_____/_____/_____
Active
Closed
Non-IEVS
RECIPIENTS INCLUDED IN POTENTIAL OVERPAYMENT (MFBU)
Medi-Cal Eligibility Date
Name
Date of Birth
Social Security Number
From
To
If additional space is needed, use the MC 224 A-S (Supplemental) and attach.
Section II—Possession of Other Health Coverage
Does recipient have other health coverage?
Yes (check only if not reported)
No
If yes, complete DHCS 6155 and send separately to: Department of Health Care Services, Other Health Coverage Section.
Is there also an income-related overpayment?
Yes (complete Section III)
No (go to Section IV)
Section III—Income Overpayment Computation
The share-of-cost should have increased for the period(s) _________________________________________________________________
because _________________________________________________________________________________________________________
________________________________________________________________________________________________________________
and the county was not informed: (check all that apply)
on the statement of facts
within 10 days of change stated above
On the status report
The overpayment is computed as follows: (County completes boxes 1–6.) (DHCS Investigations Branch completes boxes 7 and 8.)
For additional months of overpayment computations, use the MC 224 A-S (Supplemental) and attach.
1
2
3
4
5
6
7
8
Correct
Correct
Original
Potential
Amount Paid
Overpayment
Month/Year Correct Net Income
Maintenance Need
Share-of-Cost (2–3)
Share-of-Cost Met
Overpayment (4–5)
by Medi-Cal
(Lower of 6 or 7)
$
$
$
$
$
$
$
Section IV—County Worker Comments
(If additional space is needed, attach a separate sheet of paper.)
Section V—County Worker Completing Form
Name (print)
County
Signature
Date
EW number
Telephone number
(
)
White—DHCS Investigations
Yellow—DHCS Investigations
Pink—County
MC 224 A (06/07)
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