§ 38-59-250 — Initiation of overpayment recovery efforts.

(A)(1) An insurer shall initiate any overpayment recovery efforts by sending a written notice to the provider at least thirty business days prior to engaging in the overpayment recovery efforts, other than for recovery of duplicate payments or other similar adjustments relating to: (a) claims where a provider has received payment for the same services from another payor whose obligation is primary; or (b) timing or sequence of claims for the same insured that are received by the insurer out of chronological order in which the services were performed. (2) The written notice required by this section shall include: (a) the patient's name; (b) the service date; (c) the payment amount received by the provider; (d) a reasonably specific explanation of the change in payment; and (e) if the claim is submitted pursuant to a provider contract that includes an appeals process, the telephone number or a mailing address through which the provider may initiate an appeal, and the deadline by which an appeal must be received. (B) An insurer may not initiate overpayment recovery efforts more than eighteen months after the initial payment was received by the provider; however, this time limit does not apply to the initiation of overpayment recovery efforts: (1) based upon a reasonable belief of fraud or other intentional misconduct; (2) required by a self-insured plan; or (3) required by a state or federal government program.

Legislative History

HISTORY: 2008 Act No. 356, SECTION 1, eff one year after approval by the Governor (approved June 11, 2008); 2012 Act No. 243, SECTION 1, eff September 16, 2012.