Claims Overpayment and Retractions
Governs Sharp Health Plan's process for identifying, researching, notifying, recovering, and recording claims overpayments for contracted and non‑contracted providers in California. Affects SHP Claims Administration, Accounting, providers, and delegated providers.
No material clinical or coverage changes in this revision.
Overpayment Identification and Recovery Criteria
Overpayment identification, research, notification, recovery, and monitoring
Criteria and procedural steps the Plan follows when a claim overpayment is suspected or verified. Covered when ALL of the following apply:
ALL of the following
- Minimum data required to research an overpayment (must include all): Patient name; Claim number; Date of Service; Billed amount; Approved amount; Reason for the suspected overpayment; CMS or UB-04.
ALL of the following
- If a determination cannot be reached within 30 working days, the Claims Auditor will discuss relevant issues with the Claims Administration Manager to resolve the situation.
- If an overpayment is determined, the Claims Auditor will query other claims paid to the provider to identify any similar overpayments.
ALL of the following
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