2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Claims and Paymentnot made a recovery within 12 months from thedate Presbyterian Centennial Care first pays theclaim.Recovery from a third-party resource, PresbyterianCentennial Care, or a Presbyterian Centennial Careprovider if Presbyterian Centennial Care hasidentified a third-party resource but failed to initiaterecovery within the 12-month periodRecovery from a third-party resource, PresbyterianCentennial Care, or a Presbyterian Centennial Careprovider if Presbyterian Centennial Care hasaccepted the denial of payment or recovery from athird-party resource or when the contractor fails tocomplete the recovery within 15 months from thedate Presbyterian Centennial Care first pays theclaim. HSD may permit payments to be made inaccordance with state regulations.The exception to this 12-month period is for casesin which a capitation has been recouped fromPresbyterian Centennial Care pursuant to Article6.2.4, whereupon Presbyterian Centennial Careshall retain the sole right of recovery for all paidclaims related to members and months that wererecouped.Requesting an AdjustmentIf you believe a claim was processed incorrectly,contact our Provider CARE Unit for an explanation.They will determine if an adjustment is necessaryand request an adjustment on the claim. You maybe advised to resubmit the claim with additionalinformation. Adjustment requests must be madewith a timely manner as defined in the Timely FilingSubmission Guidelines section within thisdocument.Recovery of Claim OverpaymentsPresbyterian accepts all voluntary refunds andpursues the recovery of all claim overpayments thatare identified by the providers. Presbyterianpursues the recovery of claim overpayments whenidentified by Presbyterian or another entity otherthan the provider if the overpayment is identifiedand the provider is notified within the time framesas outlined below.The time frame for recovery is based on thenotification to the provider or their representative byEOP or other communication type (for example,letter, fax, or phone call).Exceptions to these guidelines may occur becauseof government regulations or cases of suspectedfraud and abuse activities. Claim overpayments arerecovered through the EOP process wheneverpossible. This appears as a payment reduction ornegative claim payment on your EOP.The acceptable time frames for recovery ofoverpayments are as follows:Centennial Care: One year from the date ofpayment.Exception: When COB is involved, there is no timeframe for recovery of any overpayments ifPresbyterian has documented verification that theprovider has received payment from the otherinsurance carrier.Exception: For Indian Health Services (IHS)providers, in network and out of network, a twoyearfiling limit applies.Commercial and Administrative Service Only(ASO): One year from the date of payment.18-132014 Practitioner and Provider Manual - Ver. 3