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Back  RFI # 1033: Claim Overpayment Recovery

Formal vs. Informal Help Informal Formal


MaryAnne Zingaro


We have a process to manage overpayment recovery through our finance department. Its only when we don’t get refund back from providers that 835 kicks in.
1.Overpayment is identified & Letter from Finance is sent to provider for overpayment & claims involved.
If the providers refund within the timeframe: 1) opened account is closed in financial system; 2) Nothing is reported on 835 for withholds or refunds
If the providers do not refund the timeframe: 1) opened account balance is forwarded to claims system from Finance; 2) overpayment recoupment is initiated; 3) withholds are reported on the 835 per IG (PLB with WO qualifier & ref number for the invoice)
If we resolve the open AR manually, do we have to report it on the 835 OR is it consider closed and nothing is reported on the 835?


This issue is explicitly addressed in guide 005010X221. Section 1.10.2 states "This section and all subsections identify the business structure of the 835 and specific solutions or usage that relate to health care claim payment and remittance business issues. These solutions may not be the only possible solutions within an ASC X12 835 transaction. They are, however, the only solutions for the business situations identified that are compliant with this implementation guide. Creation of 835 transactions that are not consistent with the information here is prohibited under this implementation." Section states "If the provider chooses to remit the balance due within the specified time period with a check, the health plan will acknowledge the receipt of the check using the PLB segment of the next 835."

Therefore, even if an AR is resolved manually, the acknowledgment must be reported in the 835.
Submission 4/26/2010
Status Date 5/5/2010
Status F - Final
Primary References
Document 005010X221
Set ID?