Look Back Periods to Reconcile Overpayments

Date Issued: 11/22/2012

(Applies to: All Plans)

To ensure fair and accurate claims payment, EmblemHealth conducts audits of previously adjudicated claims. The time period for these audits is referred to as the “Look Back Period.” Claims may be audited based on the settlement or paid/check date, not the date(s) of service. The date range for each audit is primarily determined by regulatory requirements and varies with the member’s plan type. The Look Back Periods are summarized in the table below (and may be modified as needed to reflect statutory, regulatory changes and exceptions).

Plans Look Back Period
Commercial Plans 2 years
FEHB Plans and Medicaid Reclamation Claims 3 years
Medicare Advantage Plans

Pre-American Taxpayer Relief Act of 2012
Within one year for any reason and 3 years after the year in which payment was made for good cause (new and material evidence has come to light)

Post-American Taxpayer Relief Act of 2012
Within one year for any reason and 5 years after the year in which payment was made for good cause (new and material evidence has come to light)

 

Medicaid, Child Health Plus, Family Health Plus and Veterans Administration (VA) Facilities’ Claims* 6 years
*No unilateral offset permitted.

If an overpayment is identified, notices and requests for repayment will be sent to the provider. The notices will provide a detailed explanation of the erroneous payment, as well as instructions for repayment options and how to dispute the repayment request. The provider may challenge an overpayment recovery by following the Provider Grievance process set out in the applicable Dispute Resolution section of the Provider Manual: Commercial/Child Health PlusMedicaid/Family Health Plus or Medicare.

If the overpayment is not returned within the requested time frame or the dispute of overpayment is not submitted in a timely manner, EmblemHealth will withhold funds from future payment(s) to the provider up to the amount of the identified overpayment.

Note: These time frame limitations do not apply to:

  • Claims that fall under the False Claims Act
  • Duplicate claims
  • Fraudulent or abusive billing claims
  • Claims of self-funded members
  • Claims of members enrolled in coverage provided by the state or a municipality to its employees
  • Claims subject to specifically negotiated contract terms between an EmblemHealth company and a provider; contractual time frames will apply

Also important to note:

Commercial Plans

  • Section 3224-b of the Insurance Law limits recovery of overpayments to 24 months.
  • Notice must be sent to provider specifying the patient name, service date, payment amount, proposed adjustment and a reasonably specific explanation of the proposed adjustment.
  • The 24-month limitation does not apply to: (i) claims that are fraudulent or abusive billing; (ii) claims of self-funded plan members; (iii) claims of members enrolled in a state or federal government program; or (iv) claims of members enrolled in coverage provided by the state or a municipality to its employees.

FEHB Plans

  • 30/60/90-day interval notices must be sent to provider; offset may occur if debt remains unpaid and undisputed for 120 days after first provider notice.
  • The 3-year look back limitation does not apply to False Claims Act claims.
  • Provider Notice must provide: (a) an explanation of when and how the erroneous payment occurred; (b) the appropriate contractual benefit provision (if applicable); (c) the exact identifying information (i.e., dollar amount paid erroneously, date paid, check number, etc.); (d) a request for payment of the debt in full; (e) an explanation of what may occur should the debt not be paid, including possible offset to future benefits; (f) offer installment options; and (g) provide the provider with an opportunity to dispute the existence and amount of the debt.

Medicaid Reclamation Claims

  • NYS has the right to recoup payments from EmblemHealth that Medicaid fee-for-service paid on behalf of a patient who has commercial insurance.

Medicaid, Child Health Plus and Family Health Plus

  • Required by Model Contract with SDOH.