Overpayment Recovery

REIMBURSEMENT POLICY STATEMENTIndiana Medicaid Policy Name & Number Date Effective Overpayment Recovery-IN MCD-PY-1111 07/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to, those health care services or suppli es that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or si gnificant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also inc lude those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Rei mbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan c ontract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may mo dify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the li mitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. … 5 F. Related Policies/R ules ………………………….. ………………………….. ………………………….. ….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. .. 5 H. References ………………………….. ………………………….. ………………………….. …………………. 5 Overpayment Recovery-IN MCD-PY-1111Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectOverpayment Recovery B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. Theinclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Retrospective review of claims paid to providers assist CareSource with e nsuringaccuracy in the payment process. CareSource will request voluntary repayment from providers when an overpayment is identified.Fraud, waste , and abuse investigations are an exception to this policy. In theseinvestigations, the look back period may go beyond 2 years.C. Definitions Claims Adjustment Adjustment is defined as a claim that was previously paid and is being updated for one of the following reasons: o denied as a zero payment o a partial payment o a reduced payment o a penalty applied o an additional payment o a supplemental payment Overpaymen t Any payment made to a network provider by a Managed Care Organization (MCO) to which the network provider is not entitled to under Title XIX of 42 C .F.R. o A claim adjustment is only considered to result in an overpayment when a claim that previously p aid is updated to a denied status as a zero payment or results in a reduced payment. Explanation of Payment (EOP ) A statement contain ing the payment and adjustment information for claims the provider has submitted for payment to CareSource. Overpayment Recovery-IN MCD-PY-1111Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Coordination of Benefits (COB) A payment from another carrier that is received after a payment from CareSource; and the other carrier is the primary insurance for the member. Retroactive Eligibility A payment for a member who was retroactively terminated by the state. The member is not eligible for benefits. Improper Payment A payment that should not have been made or an overpayment was made. Exam ples include, but are not limited to: o payments made for an ineligible member o ineligible service payments o payments made for a service not received o duplicate payments Credit Balance / Negative Balance Funds that are owed to CareSource as a result of a claim adjustment. Provider Level Balancing (PLB ) Adjustments to the total check / remit amount occur in the PLB segment of the remit. The PLB can either decrease the payment or increase the payment. T he sum of all claim payments (CLP) minus the sum of all provider level adjustments (in the PLB segment) equals the total payment. (Beginning Segment for Payment Order/Remittance Advice (BPR ), which means total payment within the EOP ). Forwarding Balance (F B) An adjustment that occurs within an EOP to a claim with a prior paid amount. The FB amount does not indicate funds have been withheld from the providers payment for this remittance advice. It only indicates that a past claim has been adjusted to a di fferent dollar amount and that funds are owed to CareSource. D. PolicyI. CareSource will provide all the following information when seeking recovery of an overpayment made to a provider : A. the name and patient account number of the member to whom the service (s) were provided ; B. the date(s) of services provided C. the amount of overpayment D. the reason for the recoupment E. that the provider has a ppeal rights II. Overpayment RecoveriesA. Lookback period is 24 months from the claim paid date. B. Advanced notification will occur 60 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. Overpayment Recovery-IN MCD-PY-1111Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 III. Coordination of Benefit RecoveriesA. Lookback period is 12 months from claim paid date. B. Advanced notification will occur 60 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. IV. Retro Active E ligibility RecoveriesA. Lookback period is 24 months from da te CareSource is notified by Medicaid of the updated eligibility status. B. Advanced notification will occur 60 days in advance of recovery. V. Management of Claim Credit Balances.A. Regular and routine business practices, including, but not limited to, the updating and/or maintenance of a providers record, can create claim credit balances on a providers record. This may result in claim adjustments, both increases and/or decreases in claim paid amounts, and/or forward balancing may move a providers record into a negative balance in which funds would be owed to CareSource. This information will be displayed on the EOP in the PLB section. B. Negative balance status and the associated rec onciliation of that balance that is the result of a claim adjustment that increased the claim paid amount is not considered to be an overpayment recovery and does not fall under the terms of this policy. 1. Claim Adjustment Example a. A claim paid $10 previousl y but was updated to pay $12. The adjustment created a $10 negative balance and paid the provider the full $12 when adjusted, instead of the $2 difference. b. The $10 negative balance is not considered to be an overpayment subject to the guidelines outlined in section D.I D.IV. 2. Overpayment Example a. A claim previously paid $12 but is updated to pay $10. The claim adjustment with the $2 reduced payment is subject to the guidelines outlines in section D.I D.IV. b. The reduced payment will trigger a 30-day adv anced notification with the details related to the claim and overpayment. C. Reconciliation of negative balance status will be done through claims payment withholds for otherwise payable claims until the full negative balance has been offset, unless otherwise negotiated. D. Providers are notified of negative balances through EOPs and 835s. Providers are expected to use this information to reconcile and maintain their accounts receivable (AR) to account for the reconciliation of negative balances. E. Notification of negative balances and reconciliation of negative balances may not occur concurrently. Providers are expected to maintain AR for the reconciliation of negative balances when that occurs. Overpayment Recovery-IN MCD-PY-1111Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 VI. In the event of any conflict between this policy and any written agreement between the provider and CareSource, that written agreement will be the governing document. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropr iate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. F. Related Policies/RulesCareSource Provider Agreement , ARTICLE V. CLAIMS AND PAYMENTS G. Review/Revision HistoryDATE ACTIONDate Issued 04/29/2020 New policyDate Revised 10/13/2021 10/26/202201/31/2024Updated definitions. Added D. V. and D. VI. Updated references. Approved at PGC. Updated references. Updated III. C. to 30 days and IV. C. to 30 days. Annual review. Removed IV. C. Updated references. Approved at Committee . Date Effective 07/01/ 2024 Date Archived H. References1. Claim Payment Errors, IND . CODE 27-13-36.2-8 (2023). 2. Claim Overpayment Adjustment, IND . CODE 27-13-36.2-9 (2023). IN-MED-P-2691376 Issue date 04/29/2020 Approved OMPP 03/25/2024