Durable Medical Equipment (DME) Upper Payment Limit (UPL) Reprocessing Accounts Receivable (AR)  Request Form

Resetting the AR to 0% prior to the clean-up implementation requires an AR increase afterwards to recoup incorrect payment. Fill out the form below. If choosing a customized AR rate, an email will be sent by the Department of Health Care Policy & Finance (the Department) regarding request approval.

If approved, the customized rate requested will be the auto-recoupment rate after the DME UPL implementation is complete.

Once the request above is approved, the Department will reset the AR to 0%, which prevents the Department from instantly recouping the incorrect payment at full amount. The AR will stay at 0% until we complete reprocessing new ICNs by the end of 2019, and then the AR will be increased from 0% to a rate preferred by your company for future payment recoupment. Please fill out the Recoupment AR Request below for future payment recoupment.

Note: Standard AR rate (25%) and customized rates higher than 25% will be automatically approved. A customized AR rate lower than 10% will automatically be denied. Customized AR rates greater or equal to 10%and lower than 25% will be approved on case-by-case basis depending on the justification provided.