Claims > Look Back Periods To Reconcile Overpayments
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).
FEHB Plans and Medicaid Reclamation Claims
|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 and Veterans Administration (VA) Facilities Claims*
*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 chapter of the Provider Manual: Commercial/CHP, Medicaid 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:
- 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.
- 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 and Child Health Plus
- Required by Model Contract with SDOH.
Glossary terms found on this page:
Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).
An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.
A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.
A payment method in which the insurer will reimburse the member or provider directly for each covered medical expense.
A request to change an adverse determination that was based on administrative policies, procedures or guidelines.
An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.
Specific circumstances or services listed in the contract for which benefits will be limited.
Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.
A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.
A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.
An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program. Also known as MA.
An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.
A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.
A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.
A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:
- Doctor of medicine
- Doctor of osteopathy
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- Clinical laboratory
- Screening center
- General hospital
- Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes
A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.
New York State Department of Health. This agency provides information for consumers, doctors, researchers and health care providers.