HIPAA Claims EmblemHealth: Look Back Periods To Reconcile Overpayments
To ensure fair and accurate HIPAA claims payment, EmblemHealth conducts audits of previously adjudicated claims. The time period for these audits is referred to as the “Look Back Period.” HIPAA claims may be audited based on the settlement or paid/check date, not the date(s) of service. The date range for each audit is primarily determined by regulatory requirements and varies with the member’s plan type. The Look Back Periods are summarized below (and may be modified as needed to reflect statutory, regulatory changes and exceptions).
- Commercial Plans – 2 years
- FEHB Plans and Medicaid Reclamation Claims – 3 years
- Medicare Advantage Plans Pre-American Taxpayer Relief Act of 2012 – Within one year for any reason and 3 years after the year in which payment was made for good cause (new and material evidence has come to light)
- Post-American Taxpayer Relief Act of 2012 – Within one year for any reason and 5 years after the year in which payment was made for good cause (new and material evidence has come to light)
- Medicaid, Child Health Plus and Veterans Administration (VA) Facilities Claims – 6 years.
No unilateral offset permitted. If an overpayment is identified, notices and requests for repayment will be sent to the provider. The notices will provide a detailed explanation of the erroneous payment, as well as instructions for repayment options and how to dispute the repayment request. The provider may challenge an overpayment recovery by following the Provider Grievance process set out in the applicable Dispute Resolution chapter of the Provider Manual: Commercial/CHP, Medicaid or Medicare. If the overpayment is not returned within the requested time frame or the dispute of overpayment is not submitted in a timely manner, EmblemHealth will withhold funds from future payment(s) to the provider up to the amount of the identified overpayment.
These time frame limitations do not apply to:
- Claims that fall under the False Claims Act
- Duplicate claims
- Fraudulent or abusive billing claims
- Claims of self-funded members
- Claims of members enrolled in coverage provided by the state or a municipality to its employees
- Claims subject to specifically negotiated contract terms between an EmblemHealth company and a provider (contractual time frames will apply).