N.J. Admin. Code § 11:22-1.8

Current through Register Vol. 56, No. 11, June 3, 2024

Section 11:22-1.8 - Reimbursement of overpaid claims

(a) No carrier or its agent shall base a reimbursement request for a particular claim on extrapolation of other claims, except under the following circumstances:

1. In judicial or quasi-judicial proceedings, including arbitration;

2. In governmental administrative proceedings;

3. Where relevant records required to be maintained by the provider have been improperly altered or reconstructed, or a material number of such records are unavailable; or

4. Where there is clear evidence of fraud by the health care provider and, if applicable, the carrier has investigated the claim in accordance with its fraud prevention plan established pursuant to 17:33A-15 and referred the claim, together with supporting documentation, to the Office of the Insurance Fraud Prosecutor in the Department of Law and Public Safety and the Bureau of Fraud Deterrence in the Department pursuant to 17:33A-9.

(b) A health carrier or its agent may request reimbursement for the overpayment of a claim only if the health carrier or agent submits a written reimbursement request to the provider within 18 months of the date on which the first payment on the overpaid claim was made.

1. The written reimbursement request shall be a separate notice to the provider and shall include:

i. A clear identification of the claim;

ii. The name of the patient and the date of the service;

iii. An explanation of the basis upon which the carrier or its agent believes the amount paid on the claim was in excess of the amount due; and

iv. Notice to the provider of his or her right to contest the reimbursement request.

2. If the reimbursement request is submitted to the provider beyond 18 months of the date on which the first payment on the claim was made, the request shall include:

i. All information set forth in (b)1 above;

ii. An explanation of the legal basis relied upon in making the request beyond the 18-month period (that is, the health benefits plan is not required to comply with the statutory requirements because it is either self-funded or issued outside of the State, or the health benefits plan is required to comply with the statutory requirements, but one of the statutory exceptions applies); and

iii. A description of the appeal process related to the request.

3. No health carrier or its agent may seek more than one reimbursement for overpayment of a particular claim.

4. No health carrier or its agent in seeking reimbursement for overpayment of a claim shall collect or attempt to collect:

i. The funds for the reimbursement on or before the 45th calendar day following the submission of the reimbursement request to the health care provider;

ii. The funds for the reimbursement if the health care provider disputes the reimbursement request and initiates an appeal pursuant to 11:22-1.10 on or before the 45th calendar day following the submission of the reimbursement request to the health care provider and until the health care provider's rights to appeal pursuant to 11:22-1.10 and 1.13 have been exhausted; or

iii. A monetary penalty against the reimbursement request, including, but not limited to, an interest charge or a late fee.

5. A health carrier or its agent may offset against a provider's future insured claims, an overpayment, to a provider on which a health carrier or its agent issued a reimbursement request pursuant to this subsection only if:

i. The offset action applies to claims submitted by the health care provider after the 45th calendar day following the submission of a reimbursement request to the provider, or after the provider has exhausted his or her rights to appeal pursuant to 11:22-1.10 and 1.13;

ii. The health carrier or its agent submits to the provider in writing a detailed offset notice so that the provider is able to reconcile each covered person's bill that is the subject of the offset action;

iii. The provider does not initiate an appeal of the reimbursement request within 45 days; and

iv. The provider was given 30 days after receipt of the offset notice to reimburse the health carrier or its agent for the overpayment and did not reimburse the health carrier or its agent.

6. A provider may contest a reimbursement request through the internal and external appeal processes set forth at 11:22-1.10 and 1.13.

7. The limitations of this subsection shall not apply:

i. Where an overpayment is the result of claims that were submitted fraudulently;

ii. Where a provider has demonstrated a pattern of inappropriate billing; or

iii. Where a claim(s) is subject to coordination of benefits (COB).

N.J. Admin. Code § 11:22-1.8

Recodified from 11:22-1.9 by 50 N.J.R. 571(a), effective 1/16/2018

Adopted by 50 N.J.R. 829(a), effective 2/5/2018