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Provider Manual

Reimbursement Recovery Process

Last Updated on September 16, 2020

Overpayment and Underpayment:  In the event an error in payment is made by either party, Security Health Plan reserves the right to adjust later payments to Provider to compensate for the Overpayment or Underpayment after the erroneous payment was made.  This right of adjustment exists notwithstanding the fact that later payments might be unrelated to those services for which the erroneous payment was made.  With the exception of self-funded business, retro eligibility changes, Fraud, Waste and Abuse, or Governmental audit or review (inclusive of encounter data reconciliation), Security Health Plan further agrees to offset such erroneous payment within twelve (12) months of the most recent claim remittance for the services billed.  

The reimbursement recovery process allows Security Health Plan to recover overpayments made by Security Health Plan  to contracted and non-contracted providers. All verifiable overpayments of a claim by Security Health Plan  will be recovered through offsets against current claim payments, aka a recoupment. Prior to each provider payment, Security Health Plan   will recoup any overpayments that are due from the provider.

Recoupment of overpayments will reflect on subsequent remittances and will include the details for claims paid as well as information identifying the recovered overpaid claims. When payments are recouped on a provider remittance advice statement, and the amount recouped is more than the amount the provider would have been paid on that remittance, it is considered a Balance Due. Future claim payments will continue to be withheld until the Balance Due amount is satisfied. Tip: If providers are in a recurring balance due amount they will need to refer back to the initial statement that put them in a balance due to find the claims that were recovered as overpaid claims and balance their accounts.

If the provider remains in a Balance Due for 30 days, providers will be issued a letter requesting payment with the remittance advice statement that generated the Balance Due amount. Following notification, providers have 60 days to return overpayments. If payment is not received at 60 days, a second request letter will be sent. If a response is not received after 30 additional days, a certified letter will be sent informing the provider the amount will be referred to Security Health Plan’s collection agency.