Overpayment Recovery

Last Reviewed: 12/18/2025

Date Issued: 11/22/2012

(Applies to: All Plans)

Provider Identified Overpayments

In general, if you identify an EmblemHealth overpayment, you are required to return the funds with the reason you believe the claim was overpaid and a copy of the explanation of payment you received with the original payment to ensure we can apply the refund correctly to our records.   

Repayments with supporting documentation should be sent to:  

EmblemHealth

P.O. Box 29101

New York, NY 10087

If the member is on a Medicaid or Child Health Plus plan, self-disclosure is required by the New York State Department of Health’s Model Contract. For details on self-disclosure requirements, visit the New York State Office of the Medicaid Inspector General’s website. For Medicaid Reclamation Claims, New York State has the right to recoup payments from EmblemHealth that the Medicaid fee-for-service program paid on behalf of a patient who has commercial insurance.

If you have questions, please sign in to emblemhealth.com/providerportal and use our live agent chat or Message Center to contact us. A Provider Customer Service Representative will be happy to help.

Plan Identified Overpayments

If we identify an overpayment, we will adjust your claim and send you an Explanation of Payment (EOP).

EmblemHealth will also send a letter to the provider requesting a refund of the overpayment. The letter will give a detailed explanation of the incorrect payment, and instructions for repayment options and how to dispute the 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.

Example: Recoupment from future payment

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 payment 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. 

Overpayment Recovery Time Frames

The following table sets out the time frames for overpayment recoveries by plan type.

*No unilateral offset permitted.

 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. The notice sent to the provider must specify all of the following:

• Patient’s name.
• Service date.
• Payment amount.
• Proposed adjustment.
• A reasonably specific explanation of the proposed adjustment.

The 24-month limitation does not apply to claims that are fraudulent or abusive billing or for members enrolled in a:

• Self-funded plan.
• State or federal government program.
• Plan with coverage provided by the state or a municipality to its employees.

FEHB Plans

EmblemHealth is required to send notices at 30, 60, and 90-day intervals to the overpaid provider. An offset may occur if the debt remains unpaid and undisputed for 120 days after first notice sent to the provider.

The three-year look back limitation does not apply to False Claims Act claims.

Provider Notice must provide all of the following:

• An explanation of when and how the erroneous payment occurred.
• The appropriate contractual benefit provision (if applicable). 
• The exact identifying information (i.e., dollar amount paid erroneously, date paid, check number, etc.). 
• A request for payment of the debt in full. 
• An explanation of what may occur should the debt not be paid, including possible offset to future benefits. 
• Repayment installment options. 
• An opportunity to dispute the existence and amount of the debt.

Our Overpayment Process

When a claim overpayment is identified, we will adjust your claim by reversing the original payment and send you an EOP with remit code FB (Forward Balance). This indicates the difference between the original claim and the overpayment/adjustment. No recoupment is taken at this time. 

Example: Notification of overpayment