Overpayment recovery policy

Timelines for recovering an overpayment

Priority Health handles recovery of overpayments ("take-backs") according to the situation that created the overpayment and the time frame between when the payment was made and when the overpayment was identified.

• Member retro-terminations: Recovery will be limited to 12 months from date of payment. Member liability exists.
• Coordination of benefits: Recovery will be limited to 12 months from date of payment. Member liability may exist.
• Inaccurate payment: This includes duplicate payment, system set-up error, claim processing error, claims paid to wrong provider. Recovery will be limited to 12 months from date of payment.
• Identified through a medical record audit: Recovery will be limited to 18 months from date of payment. Time period starts from audit notification date.
• Fraud and abuse: Recovery time period will be the statute of limitations.

For more information, providers should review their Priority Health contracts.

Tracking the take-back/credit balance forward (CBF)

You should refund any overpayment as soon as it is identified.  See the refund procedure on our Making corrections page in this manual.

• If, after 90 days, we have not received your refund, our Finance Department will automatically take the payment back on a future remittance advice. If we receive no further claims from you, we may place the take-back in collections.
• The take-back amount will appear as a negative payment on the remittance advice that is offset with dollars being paid on another claim for a member with the same plan (HMO, POS, PPO, etc.).
• Each self-funded (SF) group is its own line of business, so Priority Health can only take back dollars from a paid service to the same provider for another member in the same group. 
• If the dollar amount of the overpayment is greater than the dollar amount owed you on the remittance advice, there will be no check issued you with the RA. In this case, the take-back amount may be taken out of more than one remittance advice until the amount is recovered.
• You will see the claim that created the take-back amount on the last page of the remittance advice.

Monthly statement of outstanding overpayments

Priority Health Finance sends a monthly statement of the outstanding overpayment to the provider until the overpayment is settled. This statement will list:

• Patient account information
• Date of service
• Billed changes
• Date claim was originally paid
• Reason for take-back

Go to information on correcting overpayments and remittance advices.