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Non-UPP Providers
The Payment Recovery Program became effective October 1, 2004. This program allows us to recoup overpayments made to BCBSIL contracting providers for the BlueChoice POS, BlueChoice Select and PPO products when payment errors have occurred (e.g. duplicate payments, non-covered services).
Refund Request Process
When we identify an overpayment, a refund request letter is sent to the payee which explains the reason for the refund and includes a remittance form and return address envelope. If the contracting provider fails to return the overpayment, BCBSIL reserves the right to deduct any such payment from any other payment due the provider from BCBSIL.
Electronic Remittance Advice
Your Electronic Remittance Advice (ERA), will provide information in a PLB segment when an overpayment is recovered by BCBSIL. Providers receiving old ERA formats NSF, ANSI 3030 and 3051 will have to check the Provider Claim Summary (PCS/EPS) reports to verify overpayment information.
The ANSI 835 4010A1 will be displayed as follows:
- PLB*123456978*20041231*WO:0000123456789X*25.30~
- PLB01 = Provider Identifier (Provider #)
- PLB02 = Fiscal Period (CCYYMMDD)
- PLB03-01 = Adjustment Identifier (WO = Overpayment Recovery)
- PLB03-02 = Provider Adjustment Identifier = DCN # will be provided
- PLB04 = Provider Adjustment Amount
Provider Claim Summary/Electronic Payment Summary Revisions
The recoupment deduction information will be included on your Provider Claim Summary (PCS) and Electronic Payment Summary (EPS). Modifications have been made to the PCS/EPS to support the auto-recoupment process. The PCS/EPS will:
The Recovery of Overpayments Due BCBSIL policy is located in the Health Care Management Administrative Policy and Procedure section of the BCBSIL Provider Manual.
If you have any questions about this policy, please contact our Provider Telecommunications Center at (800) 972-8088.
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