If a Provider identifies that a payment made by BCBST results in an overpayment, it is the responsibility of the Provider to reimburse BCBST the overpaid amount. The Provider should return the overpayment with a copy of the Remittance Advice (RA) and a cover letter explaining why the payment is being refunded. A sample copy of the Commercial Remittance Advice can be found on the company website at
http://www.bcbst.com/providers/Sample-Copies-of-Remittance-Advices.page. Mail to: BlueCross BlueShield of Tennessee
Receipts Department 1 Cameron Hill Circle Chattanooga, TN 37402
In the event that a Provider receives a BCBST overpayment notification, no action is required unless records conflict with the findings. BCBST will recover the overpayment through an offset to the remittance advice within 45 days from the date of the notification. Please do not send a check for the overpayment.
a. Overpayment Notifications
An overpayment notification is sent on all overpayments that are identified on claims submitted by Physicians, non-participating facilities and par facilities requiring notification.
Requests for reimbursement of overpayment shall be made no later than eighteen (18) months after the date that BCBST paid the claim submitted by the Provider, except in the case of Provider fraud, in which case no time limit shall apply. In addition, the limited period shall not apply to any federal governmental program, including the Federal Employee Program (FEP).
Notwithstanding anything to the contrary, BCBST’s review of relevant financial and/or medical records shall not be limited for the time period of eighteen (18) months nor shall BCBST be prohibited to pursue any other available remedy, either at law or in equity. The following instructs Providers how to read BCBST’s Remittance Advice transactions when overpayment recovery activity is reflected:
b. Automatic Overpayment Recovery
Auto-recovery adjustment/moneys recovered: (when full recovery of overpayments is taken from current BCBST Remittance Advice):
- If there is a negative amount in the “Amount Paid” column on the remit, this indicates an overpayment adjustment has occurred on the Member’s account.
- For each account that is being adjusted, there will be a second line entry immediately following the adjustment line. This line entry reflects the corrected net amount paid for the claim (adjusted amount subtracted from the original payment).
Exception: If the overpayment was the result of 1) payment made to an incorrect Provider, 2) a duplicate payment, 3) a claim billed in error, or 4) payment made on an incorrect Member, the negative adjustment line will indicate the recovery and there will not be a second line entry.
- The second line entry has the corrected amounts listed in the “Covered Charges”, ”Provider Contract Adjustment” and “Patient Owes” columns. Please use the corrected amount in these columns to adjust the
Member’s account accordingly.
- The explanation code reflected in the “Note” column indicates the reason for the adjustment.
- On the last page of the Remittance Advice, (bottom of page), the columns are totaled, including any negative adjustments listed on the remit. In the “Amount Paid” column, the amount listed should equal the amount of payments and adjustments listed in the “Remittance Advice Detail”. Note: The “Amount Paid” column will not always equal the amount of the check when BCBST recovery amounts are carried from one Remittance Advice to the next.
It is important that Providers post all negative adjustments to a “payables” account when posting from the remit. By posting to a “payables” account, the Provider’s records will show funds owed to BCBST. This account can then be adjusted when the moneys are actually recovered by BCBST.
Auto-recovery adjustment/credit balance remains:
- On the last page of the Remittance Advice, (bottom of page), the columns are totaled, including any negative adjustments listed on the remit. A negative amount in the “Amount Paid” column indicates there were insufficient funds on the remit to recover all the funds owed to BCBST. In this situation, the credit balance will be forwarded to the next remit and deduction will be made from the total payment due the Provider on that remit.
Note: If there is a negative amount in the “Amount Paid” column, no check will be issued. However, the Remittance Advice detail should be used to post all Member accounts listed on the remit.
- When a credit balance is created, a “Remittance Adjustment” and “Adjustment Details” section will be added to the remit. These sections list any negative balances that have been carried over from any previous remits. These sections also indicate how much of the negative balance was applied to the current remit payment. Any remaining negative balance will continue to be recorded in this section until the negative balance is satisfied.
- The “Adjustment Details” section reflects the overpayments deducted from the current remit and those carried forward for deduction from a future remit. The dollar value of overpayments deducted from the current remit will be reflected in the “Currently Applied” field. The dollar amount still owed BCBST to be recovered from future remits will be reflected in the “Balance Outstanding” field.
- The “Activity Date” under the Adjustment Details” section is critical to posting Member accounts. The “Activity Date” communicates the remit date of the original adjustment transaction. In order for the Provider to identify Member-specific details required to post accounts due to overpayment recoveries carried forward from previous remits, the remit with a date matching the date listed in the “Activity Date” field must be retrieved. (It is important to retain copies of all BCBST remits for future reference.) To obtain the Member-specific claim
payment details, refer to the claim number listed under the “Adjustment Details” section on previous remits.
c. Manual Overpayment Recovery
BCBST utilizes a manual recovery transaction to recover overpayment dollars from the Provider’s check and Remittance Advice when normal activities are not successful in resolving an overpayment situation.
This process can involve transferring of overpayment dollars from one line of business to another, one Provider number and/or NPI to another, or one tax identification number to another involving the same Provider. This is effective for all overpayment dollars currently due BCBST regardless of when the overpayment was created.
Note: Prior to a manual recovery transaction, all actions required by BCBST Corporate Provider Overpayment Recovery Policy have been exhausted.
These manual overpayment recoveries will appear on the last page of the Provider’s remittance advice with a narrative description of “Manual Reduction”. Instructions on the remittance advice state “Manual Recovery Detail Sent Separately”. These claim details are mailed to the Provider’s office in advance of the BCBST check and Remittance Advice.
An overpayment claim detail fax hotline telephone number is listed on the Provider’s remit beside the “Manual Reduction Transaction” narrative. Provider’s office staff can call this hotline telephone number to request claim details supporting the manual reduction. The additional information will assist Providers when posting their BCBST Member accounts.