Claim Overpayment and Recoupment
Provider Administrative Policy
Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts
If we detect a claim overpayment or recoupment situation, we will automatically credit previously processed Blue Cross of Idaho claims on your remittance advice. The remittance advice will specify the credit and date of the original payment.
- Blue Cross of Idaho prefers that providers not return overpayments for services given to our members. Overpayments are recouped on future remittance advices. We may send back any money your return for an overpayment on a claim.
- Blue Cross of Idaho may credit or recoup routine claim overpayments up to 12 months from the last payment date. If a provider or member contract specifies a time frame other than 12 months, the contract requirements apply. Example: FEP, ASC accounts.
- Due to contracted risk arrangements with some managed care networks, claims needing an overpayment adjustment for managed care contracts must be recouped on a remittance advice. We will return overpayments sent to Blue Cross of Idaho to the provider and credit the remittance advice.
ASC Accounts - Providers returning money to Blue Cross of Idaho with the overpayment form may not see a credit on a remittance advice if the refund is for an ASC policy that has passed the claims run out period.
Host - If Blue Cross of Idaho is the host, or local plan, we will initiate an adjustment request to the processing site or home plan. If the processing site approves the adjustment request, we will indicate the adjustment on your remittance advice. Not all processing plans can complete an adjustment on one remittance advice. If this is the case, you may see a debit on one remittance and a reissue on a future remittance.
Note: Providers returning money or requesting money be recouped on the remittance advice due to third party liability payment for BlueCard claims will need to provide name, address, and phone number of Third Party Carrier. In addition, please provide a case/claim number assigned by third party carrier. Blue Cross of Idaho communicates this information to the member's home plan.
Providers accepting two payments: Two payments [coordination of benefit (COB), third party liability (TPL), Worker's Compensation or audits as allowed under the provider's contract] are not routine overpayments and can be recouped/credited outside the 12-month period.
- If you carry forward a credit balance for 90 days, Blue Cross of Idaho may send a letter requesting a refund to clear the credit balance.
- Blue Cross of Idaho may not be able to credit your remittance in some situations. When returning an overpayment, use the attached form to ensure we appropriately apply your credit. In some cases, Blue Cross of Idaho may send an overpayment letter requesting the return of a previous remittance payment.
|September 2014||Revised||Example added to second bullet|
|June2011||Revised||Clarification regarding Third Party|
|July 2009||Revised||Policy rewrite|
|May 2008||Revised||Language clarification|