NJ Admin Code §11:22-1.8(b)

October 15, 2021 5:20 am Published by

(b) A health carrier or its agent may request reimbursement for the overpayment of a claim only if the health carrier or agent submits a written reimbursement request to the provider within 18 months of the date on which the first payment on the overpaid claim was made.

(1) The written reimbursement request shall be a separate notice to the provider and shall include:

(i) A clear identification of the claim;

(ii) The name of the patient and the date of the service;

(iii) An explanation of the basis upon which the carrier or its agent believes the amount paid on the claim was in excess of the amount due; and

(iv) Notice to the provider of his or her right to contest the reimbursement request.

(2) If the reimbursement request is submitted to the provider beyond 18 months of the date on which the first payment on the claim was made, the request shall include:

(i) All information set forth in (b)1 above;

(ii) An explanation of the legal basis relied upon in making the request beyond the 18-month period (that is, the health benefits plan is not required to comply with the statutory requirements because it is either self-funded or issued outside of the State, or the health benefits plan is required to comply with the statutory requirements, but one of the statutory exceptions applies); and

(iii) A description of the appeal process related to the request.

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This post was written by julianatrang@ernenterprises.org