Attention! An update has been made to this
page.
To align with Centers for Medicare & Medicaid Services (CMS) guidelines,
AmeriHealth New Jersey will begin
recovering Medicare Advantage claim overpayments within four years of the
claims payment date. Currently, AmeriHealth New Jersey recovers overpayments up
to 18 months from the claim payment date.
Effective October 1, 2016, providers will be notified of
any Medicare Advantage claim overpayments identified with
good cause within four years of the claim payment date consistent with the CMS
guidance below.
CMS guidance
42 CFR ?405.980 gives guidance to Payers that overpayment recoveries can
occur:
- Within one year from the date of the initial determination or
redetermination for any reason.
- Within four years from the date of the initial determination or
redetermination for good cause as defined in
?405.986.
- At any time if there exists reliable evidence as defined in ?405.902 that
the initial determination was procured by
fraud or similar fault as defined in ?405.902.
- At any time if the initial determination is unfavorable, in whole or in
part, to the party thereto, but only for purpose
of correcting a clerical error on which that determination was based.
- At any time to effectuate a decision issue under the coverage appeals
process.
Per CMS requirements to ensure and maintain payment integrity, the
AmeriHealth New Jersey Corporate Financial
Investigation Department Provider Audit team will continue performing claims
audits to identify and correct improper
claims payments for Medicare Advantage in accordance with the CMS guidance.
Overpayment examples include, but
are not limited to, the following:
- billing errors, such as any deviation from National Correct Coding
Initiative (NCCI) guidelines and incorrect use of
billing modifiers;
- payment errors, such as an incorrect fee schedule rate applied to a
claim.
When such overpayments are recovered, we ask that you
make best efforts to refund any overpaid cost-sharing (i.e., copayment,
deductible, and coinsurance) that was collected from the affected members.
The AmeriHealth New Jersey overpayment recovery and appeals processes remain
unchanged.
If you have any questions, please contact your Provider Partnership
Associate.