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Claims recovery period to align with CMS

October 3, 2016


Attention! An update has been made to this page.

To align with Centers for Medicare & Medicaid Services (CMS) guidelines, Independence will begin recovering Medicare Advantage claim overpayments within four years of the claims payment date. Currently, Independence 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:

  1. Within one year from the date of the initial determination or redetermination for any reason.
  2. Within four years from the date of the initial determination or redetermination for good cause as defined in ?405.986.
  3. 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.
  4. 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.
  5. At any time to effectuate a decision issue under the coverage appeals process.

Per CMS requirements to ensure and maintain payment integrity, the Independence 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 Independence overpayment recovery and appeals processes remain unchanged.

If you have any questions, please contact your Network Coordinator.


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