210 Neb. Admin. Code, ch. 60, § 011

Current through May 7, 2024
Section 210-60-011 - Standards for overpayment recovery applicable to all insurers
011.01 No insurer shall withhold any portion of any benefit payable or request any refund, on the basis that the sum withheld or the refund requested is an adjustment or correction of an overpayment made on a prior claim arising under the same policy unless:
011.01(A) The insurer has within its files clear, documented evidence of an overpayment and written authorization from the claimant permitting such withholding procedure, or
011.01(B) The insurer has within its files clear, documented evidence that:
011.01(B)(1) The overpayment was clearly erroneous under the provisions of the policy. If the overpayment is the subject of a reasonable dispute as to facts, this procedure may not be used; and
011.01(B)(2) The error which resulted in the overpayment is not a mistake of law; and
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 of claimants, the insurer notifies the claimant within fifteen (15) days after the date that clear, documented evidence of discovery of such error is included in its file; and
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).
011.01(C) An insurer may use the procedure set forth in subsection 011.01(B)provided that the claim used to adjust the first overpayment is made no later than three years after the date of the error.
011.02 For the purpose of Section 011, the date of the error shall be the day on which the draft for benefits is issued.

210 Neb. Admin. Code, ch. 60, § 011