Last Reviewed: 11/29/2023
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 date(s) of service, not the settlement or paid/check date. The date range for each audit is primarily determined by regulatory requirements and varies by plan type. The Look Back Periods apply to both EmblemHealth and providers. The Look Back Periods for underpayments are two years for all lines of business. The Look Back Periods for overpayments 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, and Veterans Affairs (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.
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.
In certain cases, when a provider requests a change to his/her billing address or service address, a claim adjustment may be triggered resulting in a duplicate overpayment to the provider. At the time of the adjustment, the provider will be notified of the potential overpayment and the planned withholding of funds from future payment(s) to the provider up to the amount of the identified overpayment.
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 Plus, Medicaid, or Medicare.
Provider will be notified of any underpayments identified during the lookback periods.
Note: These time frame limitations do not apply to:
- Claims of members enrolled in coverage provided by the state or a municipality to its employees
- Claims of self-funded members
- Claims subject to specifically negotiated contract terms between an EmblemHealth company and a provider; contractual time frames will apply
- Claims that fall under the False Claims Act
- Duplicate claims
- Fraudulent or abusive billing claims
Also important to note:
Commercial Plans
- Section 3224-b of the Insurance Law limits recovery of overpayments to 24 months of the date the provider received the original payment.
- 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
- Required by Model Contract with New York State Department of Health.
