Insurance Overpayment Recovery Laws by State | Crossroads Health (2024)

Al 27-1-17

12 Months

An insurer, health service corporation, and health benefit plan shall not retroactively seek recoupment or refund of a paid claim after the expiration of one (1) year from the date the claim was initially paid or after the expiration of the same period of time that the healthcare provider is required to submit claims, whichever date occurs first

An insurer, health service corporation, or health benefit plan shall not retroactively seek recoupment or refund of a paid claim for any reason that relates to the COB of another carrier responsible for the payment of the claim after expiration of eighteen (18) months from the date claim was paid.

An insurer, health service corporation, and health benefit plan shall not retroactively seek recoupment or refund of a paid claim from provider for any reason, other than fraud or coordination of benefits or for duplicate payments after the expiration of one year from the date that the initial claim was paid.

AS 21.54.020

None

A healthcare insurer can recover an amount, wrongly paid to a provider at any time.

None

N/A

§20-3102

12 Months

A health care insurer shall not adjust or request adjustment of a payment or denial of claim more than one year after the date health care insurer has paid the claim. If a provider and insurer agree through contract about adjustment then even they have same length of time to request adjustment of a claim. Once claim is adjusted an insurer or provider shall owe no interest on the overpayment or underpayment resulting from the adjustment as long as the adjustment or recoupment taken within the period of 30 days of the date of claim adjustment.

None

Does not apply in cases of fraud

Ann. § 23-61-108, §23-63-1806, §25-15-201

18 Months

A health care insurer cannot seek refund of paid claim after the expiration of eighteen (18) months from the date the claim was initially paid.

A health care insurer has one hundred and twenty (120) days from the date of payment to notify the provider of a verification error and the fact that services rendered will not be covered if the error was made in good faith at the time of the verification.

Except in cases of fraud committed by the health care provider, means fraud that the insurer discovered after the eighteen (18) month period and could not have discovered prior to the end of the eighteen-month period.

110133.66 (2005 Cal ALS 441; 2005 Cal SB 634; Stats 2005 ch.44)

12 Months

Reimbursem*nt request for the overpayment of a claim shall not be made, unless a written request for reimbursem*nt is sent to provider within 365 days of the date of payment on the overpaid claims.

None

Does not apply in cases of fraud

C.R.S. 10-16-704 (2009)

12 Months

Adjustments to claims by the carrier shall be made within the time period set out in contract between the provider and the carrier. The time period shall be the same for the provider and the carrier and shall not exceed 12 months after the date of the original explanation of benefits. If no contract exists then adjustments to claims shall be made 12 months after the date of the original explanation of benefits.

Adjustments to claims related to coordination of benefits with federally funded health benefit plans, including medicare and medicaid, shall be made within thirty-six (36) months after the date of service.

Does not apply in cases of fraud

SB 764

60 Months

Insurers and HMOs are prohibited from seeking to recover an overpayment for a claim paid under a health insurance policy unless they provides written notice to the person from whom recovery is sought within five (5) years after receiving the initial claim.

None

None

D.C. Code § 31-3133

6 Months

Insurer may only retroactively deny reimbursem*nt to provider for services subject to COB during the 18-month period after the date that the health insurer paid the health care provider; or during the 6-month period after the date that the health insurer paid the health care provider.

A health insurer that retroactively denies reimbursem*nt to a health care provider shall provide a written statement specifying the basis for the retroactive denial. If the retroactive denial of reimbursem*nt results from COB, the written statement shall provide the name and address of the entity acknowledging responsibility for payment of the denied claim.

This section will not apply if information submitted was fraudulent; or improperly coded or duplicate claim or does not otherwise conform with the contractual obligations. If insurer retroactively denies reimbursem*nt for services as a result of cob the provider shall have 180 days after the date of denial, unless the insurer permits longer time insurer that denies reimbursem*nt to provider shall give provider a written notice specifying the basis for the retroactive denial. This section shall not apply to an adjustment to reimbursem*nt made as an annual contracted reconciliation of a risk-sharing arrangement.

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FL §627.6131

30 Months

If an overpayment in result of retroactive review or audit of coverage decisions or payment levels a health insurer must submit the claims details to provider within 30 months after the health insurer's payment of the claim

A provider must pay, deny, or contest the claim for overpayment within 40 days after the receipt of the claim and must pay or deny within 120 days of the receipt. Failure to the above creates an uncontestable obligation to pay the claim. The health insurer may not reduce payment to the provider for other services unless the provider agrees to the reduction in writing or fails to respond to the health insurer's overpayment claim.

Does not apply in cases of fraud

O.C.G.A. § 33-20A-62

18 Months

No carrier may conduct a post payment audit or impose a retroactive denial of payment on any claim that was submitted within 90 days of the last date of service or discharge covered by such claim unless: (1) notice of intent to conduct such an audit is provided; (2)Not more than 12 months have elapsed since the last date of service or discharge covered by the claim; (3) Any such audit or retroactive denial of payment must be completed and notice provided to the claimant of refund due within 18 months of the last date of service or discharge covered by such claim

No insurance carrier may conduct a post-payment audit or impose a retroactive denial of payment on any claim submitted after 90 days unless a written notice is provided, not more than 12 months have elapsed and it should be finalized within 24 months.

Any such audit must be completed within 18 months from the date of final discharge of claim.

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IC 27-8-5.7-10

24 Months

Insurance may request the provider to repay the overpayment or adjust a subsequent claim after the expiration of two years from the date claim is paid.

None

Does not apply in cases of fraud

191-15.33 (507B)

24 Months

Insurance may not audit a claim more than two years after the submission of the claim to insurer & not a claim billed for less than $25.00.

None

Does not apply in cases of fraud

KSA § 40-2442

18 Months

In the event that an insurer erroneously pays a claim providing benefits to which the insured person or provider is not entitled, the insurer shall not initiate a request for reimbursem*nt or refund of that erroneous payment, or in any other way seek to recoup the erroneous payment, unless such action is initiated within 18 months after the end of the month in which the erroneous payment was made.

In cases of fraud by the insured person or provider, such action may be initiated within the applicable statute of limitations pursuant to K.S.A. 60-513, and amendments thereto.

The provisions of subsection (b) shall not apply when there is a good faith dispute about the legitimacy of the claim, or when there is a reasonable basis supported by specific information that such claim was submitted fraudulently.

Y 304-17A-708

24 Months

An insurer shall not be required to correct a payment error made to a provider if the provider's request for a payment correction is filed more than twenty-four (24) months after the date that the provider received payment for the claim from the insurer.

None

Does not apply in cases of fraud

LRS 22:250.38

None

Health insurance shall provide the health care provider written notification in accordance with LRS 22:250.38. Health care provider shall be allowed thirty days from receipt of written notification of recoupment to appeal the health insurance issuer's action.

If a healthcare provider disputes insurance's notification of recoupment and a contract exists, the dispute shall be resolved according to terms of contract. If no contract exists, the dispute shall be resolved as any other dispute under Civil Code Article 2299 et seq.

None

24-A - §4303.

12 Months

The time that has elapsed since the date of payment of the previously paid claim does not exceed 12 months.

None

The retrospective denial of a previously paid claim may be permitted beyond 12 months from the date of payment only if: 1. The claim was submitted fraudulently 2. Duplicate payment 3. Services identified in the claim payment 3. Services identified in the claim were not delivered by the provider 4. Adjustment with another insurer COB 6. The claim payment is the subject of legal action.

M. A. Code section 15-1008

6 Months

A carrier may only retroactively deny reimbursem*nt paid to healthcare provider during the six month period after the date the carrier paid the claim.

18 Months when COB is involved

No limit for 1. Fraud, 2. Improperly coded, 3. Duplicate Payment, 4. a claim submitted to MCO & the claim was for services provided to a MD Medical Assistance Program recipient during a time period when Program has permanently retracted the capitation payment for the Program recipient.

HB 976

12 Months

The time which has elapsed since the date of payment of the challenged claim does not exceed 12 months.

None

The retroactive denial of a previously paid claim may be permitted beyond 12 months from the date of payment only if: (1) claim was submitted fraudulently; (2) claim payment was incorrect because the provider or the insured was already paid ; (3) health care services were not delivered by the physician/provider.

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Sec: 376.384

12 Months

Prohibit requesting a refund or offset against a claim more than twelve months after a health carrier has paid.

None

Does not apply in cases of fraud

33-22-150

12 Months

A health insurance issuer may not request reimbursem*nt or offset another claim payment for reimbursem*nt of an invalid claim or overpayment of a claim more than 12 months after the payment of an invalid or overpaid claim.

None

If insurance does not limit the time for submission of a claim for payment, then insurance may not request reimbursem*nt or offset another claim payment for reimbursem*nt of an invalid claim or overpayment of a claim more than 12 months after the payment of an invalid or overpaid clm.

Title 210 – NEB DEPT OF INS Chapter 60 (011-011.01(B))

6 Months

011.01(B)(3) The insurer has notified the claimant within six (6) months of the date of the error, except that in instances of error prompted by representations or nondisclosures

011.01(B)(4) Such notice states clearly the nature of the error the amount of the overpayment, and the three year limitation as provided in subsection 011.01(C)

None

None

None

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Insurance Code 420-J;8-b.

18 Months

No health carrier shall impose on any health care provider any retroactive denial of a previously paid claim or any part thereof unless: (a) the carrier has denial in writing to the health care provided the reason for the retroactive provider; and (b) the time which has elapsed since the date of payment of the challenged claim does not exceed 18 months.

None

Time limit can be extended belong the period of 18 months provided claim was submitted fraudulently or claim was incorrect because the provider was already paid for the services claim payment is the subject of adjustment with a different insurer.

C.17B:30-48 Chapter 352

18 Months

No payer shall seek reimbursem*nt for overpayment of a claim previously paid pursuant to this section later than 18 months after the date the first payment on the claim was made.

No payer shall seek more than one reimbursem*nt for overpayment of a particular claim. At the time the reimbursem*nt request is submitted to the health care provider, the payer shall provide written documentation that identifies the error made by the payer in the processing or payment of the claim that justifies the reimbursem*nt request.

Claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits.

None

None

None

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§ 3224-b

24 Months

Prohibit HMOs and other insurers from demanding refunds from a physician more than two years after the claim was initially paid.

Requires 30 days notice to in provider when payer is seeking a refund

Excludes Fraud, abusive billing, and the government & self funded plans.

None

None

Provider contracts with payers may detail this information

None

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Revised Code 3901.38.8 & 3901.388

24 Months

Third party insurer may recover an overpaid amount not later than two year from the date the claim was paid to the provider. The Provider should be informed about the overpayment practices through notice. Provider shall have a right to file appeal. In case of no response from the provider the carrier is free to initiate recovery practices.

None

Does not apply in cases of fraud

§36-1250.5

24 Months

Act of insurance company will be considered as unfair claim settlement practices act if insurance request refund from the provider after the period of 24 months from the date claim was paid.

None

Does not apply in cases of fraud OR if the provider AGREES to make a refund

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§ 38-59-250

18 Months

An Insurance may not initiate overpayment recovery process from provider more than 18 months after the initial payment was received by the provider.

An insurer shall initiate any overpayment recovery efforts by sending a written notice to the provider at least 30 business days prior to engaging in the overpayment recovery efforts.

Excludes Fraud, abusive billing, and the government & self funded plans.

None

None

None

None

None

§ 56-7-110

18 Months

Except in cases of fraud committed by the health care provider, a health insurance entity may only recoup reimbursem*nts to the provider during the eighteen-month period after the date that the health insurance entity paid the claim submitted by the health care provider.

If a health insurance entity or an agent contracted to provide eligibility verification, verifies that an individual is a covered person and if the health care provider provides services to the individual in reliance on the verification, the health insurance entity may not thereafter recoup a claim on the basis that the individual is not a covered person unless the recoupment occurs within six (6) months of the date that the health insurance entity paid the claim; otherwise, the health insurance entity is barred from making the recoupment unless there was fraud by the health care provider.

§ 3.70-3C

6 Months

The insurer has no later than the 180 day after provider receives payment to recover an “overpayment” must provide written notice and mention specific reasons for request of recovery of funds.

If carrier as secondary payer pays a portion of a claim that should be paid by the primary carrier, the secondary payer may recover overpayment from the carrier that is primarily responsible for that amount. If the portion of the claim overpaid by the secondary payer was also paid by the primary payer, the secondary payer may recover the amount of overpayment from the physician.

None

§ 31A-26-301.6

12 Months

The insurer may recover any amount improperly paid to a provider or an insured (a) within 24 months of the amount improperly paid for a coordination of benefits error; (b) within 12 months of the amount improperly paid for any other reason; or (c) within 36 months of the amount improperly paid when the improper payment was due to a recovery by Medicaid, Medicare, the Children's Health Insurance Program, or any other state or federal health care program.

None

None

18 V.S.A. § 9418

12 Months

A health plan shall not retrospective deny a previously paid claim unless at least 30 days notice of any retrospective denial or overpayment recovery is provided inwriting to the provider or the time that has elapsed since the date of payment of the previously paid claim does has exceeded 12 months.

None

The retrospective denial of a previously paid claim shall be permitted beyond 12 months if (1) the plan has a reasonable belief that fraud or other intentional misconduct has occurred; (ii) the claim payment was incorrect because the health care provider was already paid; (iii) health care services identified in the claim were not delivered by the provider; (iv) the claim payment is subject of adjustment with another health plan; or (v) the claim is the subject of legal action.

§ 38.2-3407.15

12 Months

Carrier can only impose retroactive denial of claim if provided the reason for denial, provider was already paid for the services and time period does not exceed the lesser of 12 months or a number of days mentioned in a contract.

None

Does not apply in cases of fraud

Chapter 48.43.600

24 Months

A carrier may not request a refund from a health care provider of a payment previously made to satisfy a claim unless it does so in writing to the provider within twenty-four months after the date that the payment was made.

A carrier may not for reasons related to coordination of benefits with another carrier (a) Request refund from a health care provider; or (b) request that a contested refund be paid any sooner than six months after receipt of the request. Any such request must specify why the carrier believes the provider owes the refund, and include the name and mailing address of the entity that has primary responsibility for payment of the claim.

Does not apply in cases of fraud

WVC § 33-45-2

12 Months

Carrier can only deny a claim where a provider was already paid for the service, claim was not covered under the service and provider not entitled to reimbursem*nt for the period of one reimbursem*nt for the period of one year from the date when the claim was paid to the provider

None

Does not apply in cases of fraud

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HB 0167 Section 26-15-124

24 Months

(ii) The notice required by paragraph (i) of this subsection is sent by the insurer within eighteen (18) months after the date of payment or twenty-four (24) months after the date of service, whichever is sooner.

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