Recoupment and Reimbursement Disputes

Audit Cooperation  

PCHP and the State Agencies may audit your claims and related records. Participating providers are required to cooperate with the audit process, including but not limited to providing timely access to records, interviews with employees, meetings with the participating provider, and responding to follow-up requests for information, all without cost to PCHP or the State Agencies.  

Audit Process  

When PCHP and the State Agencies perform an audit, they may select a sample of claims and then extrapolate the results of the sample review to the entire “universe” of your claims for the stated time period.  

PCHP will communicate the results of the audit in writing and will provide written notice of a request for repayment/refund of monies it believes were overpaid. Before PCHP engages in any recoupment of monies owed against future claims payments, it will give the participating provider an opportunity to provide additional information. 

Timing of Requests for Refund and Recoupment by PCHP, Requests for Additional Payment by Participating Providers  

PCHP and the participating provider may generally recover for overpayments (PCHP) and underpayments (participating provider’s pended or denied claims) if a written notice requesting a refund or additional payment is timely filed. PCHP must give written notice that it is seeking repayment/recoupment within two (2) years of its original processing of the claim; provided that, there is no time limit on how long PCHP may seek the recovery of money based on the participating provider’s fraud or abuse. The participating provider must give written notice requesting additional payment within 120 days of the date of PCHP’s original processing of the claim. 

Reimbursement Appeal Process  

What to do if you disagree with a declined referral or preauthorization request or refund request/what to do if you disagree with the amount of payment  

If a participating provider believes that (1) a referral/pre-authorization request has been improperly declined or the provider has been underpaid or (2) a PCHP request for refund or recoupment is not based on any actual overpayment, the participating provider must follow this Reimbursement Appeal Process as outlined below, being sure to meet the required time deadlines. If the participating provider fails to meet the deadlines, the Reimbursement Appeal will be denied, and the participating provider agrees that the additional money is owed to PCHP. 

Step 1: The first mandatory step in the Reimbursement Appeal Process is to contact PCHP to try to resolve the issue on an informal basis. Participating providers may contact PCHP (Medicaid and CHIP).  

Step 2: If informal discussions do not resolve the issue, the next mandatory step is to give PCHP written notice of your disagreement, which must occur within 120 days of PCHP’s original processing of the claim for alleged underpayments or within 30 days of receiving a request for refund. The written notice of dispute must specify the claims involved (including providing copies of the claims and related EOBs or a spreadsheet containing information on the claim forms/EOBs); and explain why the participating provider believes there has been an underpayment or no overpayment (when PCHP has requested a refund). The participating provider must meet face-to-face with a PCHP representative to discuss the content of the written notice and attempt to resolve the issue if PCHP requests such a meeting. PCHP will provide a written statement regarding its decision about the claims covered by the written notice.  

Step 3: If there is any remaining dispute after engaging in the Reimbursement Appeal Process, the next mandatory step is to resolve that dispute and any related issues through the dispute resolution process provided for in the participating provider’s participation agreement with PCHP. The participating provider agrees that it must FIRST engage in the Reimbursement Appeal Process BEFORE it may then attempt to resolve the dispute and any related issues through the dispute resolution process provided for in the participating provider’s participation agreement with PCHP (that is, it is a “condition precedent” to pursuing any further remedies against PCHP).  

Recoupment and Timing to Engage in Reimbursement Appeal Process  

If the Participating provider concedes that additional money is owed or does not file a written notice of dispute within 45 days of receiving a request for refund, PCHP may recoup (offset) the monies owed against future claims payments and may also seek recovery directly from the provider. If, after receiving the written notice and following the Reimbursement Appeal Process, PCHP again asserts that additional monies are owed, it may begin recoupment (offset) against future claims if the participating provider does not then follow the steps in the Dispute Resolution Process within 45 days of receiving PCHP’s written notice regarding the participating provider’s written notice of dispute.