CurrentCareSourcePolicy N/A

Overpayment Recovery / Reimbursement Policy

Defines CareSource's process for identifying and recovering overpayments for Arkansas PASSE providers, including notification, lookback periods, and reconciliation expectations; applies to network providers submitting claims to CareSource in Arkansas.

Policy Summary

PayerCareSource

PolicyOverpayment Recovery / Reimbursement Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2024

Next Review DateN/A

Key ActionProviders must submit accurate CPT/HCPCS codes, monitor EOP/835 notifications, and reconcile accounts receivable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18 moLookback - general / retroactive

12 moLookback - COB

60 daysAdvance notice before recovery

05/01/2024Effective date

Overpayment Recovery Criteria and Procedures

Overpayment recovery criteria and procedures

Policy Summary

PayerCareSource

PolicyOverpayment Recovery / Reimbursement Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2024

Next Review DateN/A

Key ActionProviders must submit accurate CPT/HCPCS codes, monitor EOP/835 notifications, and reconcile accounts receivable.

SourceLink

On This Page

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ALL of the following

amount of the recoupment
covered person's name to whom the recoupment applies
patient identification number
date or dates of service
service or services on which the recoupment is based
pending claims being recouped or future claims that will be recouped
specific reason for the recoupment

ALL of the following

General overpayment and retroactive eligibility recoveries: 18 months from the date the claim was paid.
Coordination of Benefits (COB) recoveries: 12 months from last date of service or discharge.

ALL of the following

Providers will receive 60 days advance notification prior to recoupment.
If recovery occurs outside original timely filing limits, providers may submit corrected claims within 60 days as allowed by CareSource.

ALL of the following

An adjustment is considered an overpayment only when a previously paid claim is updated to a denied status as a zero payment or results in a reduced payment.
Negative balances created by claim adjustments that increase paid amounts are not considered overpayments and are reconciled via withholds on otherwise payable claims unless otherwise negotiated.

ALL of the following

Providers are responsible for submitting the most accurate and appropriate CPT/HCPCS code(s) and modifiers for services rendered.
Providers are notified of negative balances through EOPs and 835s and are expected to reconcile accounts receivable using those notifications.

ALL of the following

This Policy does not ensure authorization or reimbursement; the plan contract (Evidence of Coverage) controls if conflict exists between this Policy and the plan contract.
If there is a written agreement between the provider and CareSource that conflicts with this Policy, the written agreement governs.

Examples

Example: A prior $12 payment updated to $10 is an overpayment subject to recovery and 60-day notification.
Example: A prior $10 payment updated to $12 creating a negative balance is not an overpayment under this policy.

Billing, Adjustments, and Code Guidance

General billing requirementmixed

HCPCS	Approved HCPCS codes must be submitted along with appropriate modifiers, if applicable.
CPT	Approved CPT codes must be submitted along with appropriate modifiers, if applicable.

Overpayment definition threshold

ThresholdAn adjustment resulting in a previously paid claim updated to a denied zero payment or a reduced payment constitutes an overpayment.

ContextOverpayment is any payment made to a network provider by an MCO to which the provider is not entitled under Title XIX of 42 CFR.

ExamplesExample: A prior $12 payment updated to $10 is an overpayment subject to recovery; a prior $10 updated to $12 creating a negative balance is not considered an overpayment.

Provider Obligations, Notifications, and Timelines

Documentation Required

Submit accurate codes and reconcile AR; monitor EOP/835 notifications

Providers must submit the most accurate and appropriate CPT/HCPCS code(s) and modifiers for services rendered, and are expected to reconcile and maintain their Accounts Receivable (AR) using EOPs and 835s which will notify providers of negative balances. Reconciliation of negative balances may not occur concurrently with notification; providers must account for negative balances until resolved. If a provider agreement with CareSource conflicts with this policy, the written agreement governs.

Submit accurate CPT/HCPCS codes and appropriate modifiers for each service provided (responsibility of submitting provider).
Providers are notified of negative balances through EOPs and 835s and are expected to use those notices to reconcile and maintain AR.
Notification and reconciliation may not be concurrent; maintain AR to account for reconciliation when it occurs.
Provider written agreements with CareSource govern in case of conflict.

Billing Rule

60-day advance notification and 60-day corrected-claim window

CareSource will provide at least 60 days advanced notification prior to any recoupment. If recovery occurs outside the original timely filing limits, providers may submit corrected claims within 60 days from the date of the recovery; otherwise normal timely filing limits apply.

Advanced notification of recovery will occur 60 days in advance of recoupment.
Corrected claims are allowed within 60 days from the date of recovery when the recovery occurs outside original timely filing limits; otherwise normal timely filing limits apply.

Key Terms

Overpayment — definition

DefinitionOverpayment: Any payment made to a network provider by a Managed Care Organization (MCO) to which the network provider is not entitled under Title XIX of 42 CFR.

When an adjustment is an overpaymentA claim adjustment is considered an overpayment only when a claim that previously paid is updated to a denied zero payment or results in a reduced payment.

Improper payment examplesPayments for an ineligible member, ineligible service, service not received, or duplicate payments are examples of improper payments/overpayments.

Claims Adjustment — definition

DefinitionClaims Adjustment: A claim that was previously adjudicated and is being updated for reasons such as denial as a zero payment, partial payment, reduced payment, penalty applied, additional payment, or supplemental payment.

Credit/Negative BalanceA credit balance/negative balance indicates funds owed to CareSource because of a claim adjustment.

Forwarding Balance (FB)An adjustment in an EOP to a claim with a prior paid amount that does not indicate funds withheld for that remittance advice but shows past adjustments.

Coordination of Benefits (COB) — lookback & definition

COB lookback periodCOB recoveries: 12-month lookback from the last date of service or discharge.

COB definitionCoordination of Benefits (COB): A payment from another carrier received after a payment from CareSource when the other carrier is primary for the member.

NotificationProviders are notified of negative balances and payment/adjustment information through EOPs and 835s for reconciliation.

Retroactive Eligibility — lookback & definition

Retroactive eligibility lookbackLookback period: 18 months from the date CareSource is notified by Medicaid of the updated eligibility status.

Retroactive eligibility definitionRetroactive Eligibility: A payment for a member who was retroactively terminated by the state and therefore not eligible for benefits.

Advanced notificationCareSource will provide 60 days advance notification prior to recovery for retroactive eligibility recoveries.