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Back  RFI # 1956: Overpayment Recovery pat id

Formal vs. Informal Help Informal Formal

Submitter

Holly George

Description

In the 835 5010 TR3, section 1.10.2.17 reviews the process of Claim Overpayment Recovery and indicates there are 3 business approaches to this.

This question is coming from a provider's perspective as opposed to a payer. When any of these 3 methods are used, is there a way to report information on the patient account the overpayment was made on?

This would be aside from the CLP07 (payer claim control number). The provider would need information that relates to the data within their practice management system such as member ID, patient control number, etc. If this is possible it will save time for the provider office trying to track down which patient account the overpayment is being recovered for.

Submitter Assigned Keywords

Identify patient account with overpayment

Response

The 835 is intended to be processed in a computer to computer environment. Since there is no guarantee that CLM01 in the claim (or the paper account number) is unique, it couldn't be used as a tracking number to provide a unique tie.

Tracking can be done back to the original patient, but requires actions by the provider or the provider's system from the start of the process, recording appropriate information related to the overpayments. Ideally, this is automated.

When the reversal and correction process is used and recoupment is immediate, no tracking is needed since patient information, such as the provider's identifier in CLP01, is included.

When the reversal and correction process is used and recoupment is delayed, the reversal and correction identifies the related claim in both CLP01 and CLP07. The value from CLP07 is then used as the overpayment recovery identifier in the PLB of the same 835, and can be associated back to the original CLP01 and patient information from the reversal and correction when the recoupment happens.

When the recoupment notification is sent by letter, the letter needs to identify the reason and details - including identification of the claim and patient - with an ID number (FCN) for tracking. When the overpayment recovery is then taken in the 835, the tracking number (FCN) points back to the letter and the detail.

Recommendation

Other organizations have written papers on overpayment recovery that may be of use. See WEDI at http://www.wedi.org/docs/resources/issue-brief-overpayment-recovery-5010-education.pdf?sfvrsn=0 and the American Medical Association at http://www.ama-assn.org/resources/doc/psa/x-pub/overpayment-whitepaper.pdf.
Submission 8/4/2014
Status Date 9/22/2014
Status F - Final
Primary References
Document 005010X221
Section1.10.2.1
Page48