Manual do Provedor

overpayment recovery

Providers should submit claims consistent with national, state, and industry standards.  To ensure adherence to these standards, Carelon relies on claims edits and investigative analysis process to identify claims that are not in accordance to national, state, and industry standards and therefore were paid in error.  The claims edits and investigative analysis process includes, but is not limited to CMS’ National Correct Coding Initiative (NCCI).  Examples of claim edits can include, but are not limited to, the following:

  • Procedure-to-procedure (PTP) edits that define pairs of HCPCS/CPT codes that should not be reported together.
  • Medically Unlikely Edits (MUE) units-of-service-edits.  This component defines for each HCPCS/CPT code the number of units of service that is unlikely to be correct and therefore need to be supported by medical records.
  • Other Edits for Improperly Coded Claims-regulatory or level of care requirements for correct coding, including and not limited to:
    • Invalid procedure and/or diagnosis codes
    • Invalid code for place of service
    • Invalid or inappropriate modifier for a code
    • State-specific edits to support Medicaid requirements
    • Diagnosis codes that do not support the procedure
    • Add-on codes reported without a primary procedure code
    • Charges not supported by documentation based on review of medical records
    • Claims from suspected fraudulent activities for provider and members that warrant additional review and consideration
    • Services provided by a sanctioned provider or provider whose license has been revoked or restricted
    • Incorrect fee schedule applied
    • Duplicate claims in error
    • No authorization on file for a service that requires a prior authorization

Providers should routinely review claims and payments in an effort to assure that they code correctly and have not received any overpayments. Carelon will notify provider of overpayments by Carelon, clients and/or government agencies, and/or their respective designees.  Overpayment include but are not limited to:

  • Claims paid in error
  • Claims allowed/paid greater than billed
  • Inpatient claim charges equal to the allowed amounts
  • Duplicate payments
  • Payments made for individual whose benefit coverage is or was terminated
  • Payments made for services in excess of applicable benefit limitations
  • Payments made in excess of amounts due in instance of their party liability and/or coordination of benefits
  • Claims submitted contrary to national and industry standards such as the CMS National Correct Coding Initiative (NCCI), procedure-to-procedure edits (PTP) and medical unlikely edits (MUE).