Submission Checklist and FAQs

Self-Disclosure Submission Checklist

A self-disclosure submission requires completion of a Self-Disclosure Form and a Claims Data File of affected Medicaid claims. Note, the Claims Data File is embedded in the Self-Disclosure Form.

Claims should include the following:

___Claim Reference Number (CRN) or Transaction Control Number (TCN), a 16-digit number

___Provider’s Medicaid MMIS ID and/or NPI number

___Medicaid group ID number (applicable if only submitted on claim)

___Medicaid recipient’s first name

___Medicaid recipient’s last name

___Medicaid recipient’s CIN, an 8-character number (e.g., AA#####A)

___Date of service (not the date billed)

___Incorrect rate or procedure codes, if applicable

___Correct rate or procedure codes

___Amount paid

___Amount that should have been paid, if applicable

___Amount paid by Medicare or any other third party, if applicable

NOTE: Do not include a check for overpayment. Do not void or adjust the claims after they are submitted for review.

After OMIG’s review of all disclosure submission material, you will receive a final letter indicating the overpayment dollar amount and the procedure for submitting the payment. If the submitted claim data does not materially match OMIG’s payment data, you will be contacted before a final letter is issued.

For questions or additional information, send an e-mail to [email protected] or call 518-402-7030.

Frequently Asked Questions (FAQs)

What is OMIG’s self-disclosure process?

  • The self-disclosure is examined to ensure reporting criteria are met
  • Submitted data are reviewed and verified
  • Discrepancies are addressed with the provider/contact person
  • Final letter is issued to the provider/contact person
  • Provider remits payment (unless claims were previously voided)

When and where do I submit a self-disclosure?

The federal Affordable Care Act requires providers to report, explain, and repay overpayments within 60 calendar days of identification. See Submission Information and Instructions

What information am I required to report?

Inappropriate Medicaid payments, including but not limited to:

  • Billing errors
  • Fraudulent behavior by employees or others
  • Discovery of an employee on the Excluded Provider list
  • Documentation errors that resulted in overpayments
  • Overpayments that resulted from changing billing systems

What information should NOT be reported?

  • When a provider’s overpayment is included in another separate review or audit being conducted by OMIG, the Office of the Inspector General, Attorney General, etc. Providers are required to seek permission from the investigating entity before voiding or adjusting claims.
  • When a provider’s overpayment is included in a broader state-initiated rate adjustment cost settlement or other payment adjustment mechanisms. For example: retroactive rate adjustments, charity care, cost reporting, etc.
  • Underpayments – Any underpayments must be re-billed to eMedNY; claims are subject to their own rules and regulations.

Am I required to report damaged, lost, or destroyed records? 

What is the Claims Data File used for?

Complete the Claims Data File to disclose overpaid claims.

What is the Mixed Payer Calculation File used for?

Complete the Mixed Payer Calculation File to determine the repayment amount for excluded individuals whose salaries were paid through multiple sources.

How do I make a payment to Medicaid?

  • Check or Money order: PLEASE DO NOT SEND PAYMENT ALONG WITH YOUR SELF-DISCLOSURE. Once your self-disclosure is processed you may pay by check or money order.
  • Voiding/Adjusting your claims: We request that if the provider wishes to void or adjust claims, the transactions are completed prior to submission of the self-disclosure.
  • Stipulation Agreement: This is a contractual agreement with OMIG to repay a self-disclosure over time. This option is available if repayment in full by check, money order, or voids is not financially feasible for your organization.

Contact OMIG’s Self-Disclosure Unit by email at: [email protected] or by phone: 518-402-7030.