Overpayment Procedures
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
If a provider is aware of receiving an overpayment made by Health Net including, but not limited to, overpayments caused by incorrect or duplicate payments by Health Net, errors on or changes to the provider billing or payment by another payer who is responsible for primary payment, the provider must promptly refund the overpayment amount to the Health Net Overpayment Recovery Department with a copy of the applicable remittance advice (RA) and explanation of payment (EOP) and a cover letter indicating why the amount is being returned. If the RA and EOP are not available, provide member name, date of service, payment amount, the member identification (ID) number, provider tax ID number, and provider ID number.
A refund to Health Net is necessary when a claim is processed incorrectly and results in an overpayment. When Health Net determines that an overpayment has occurred, Health Net notifies the provider of services in writing through a separate notice that includes the following information:
- Member name.
- Claim ID number.
- Clear explanation of why Health Net believes the claim was overpaid.
- The amount of overpayment, including interest and penalties.
The provider of service has 30 business days to submit a written dispute to Health Net if the provider does not believe an overpayment has occurred. In this case, Health Net treats the claim overpayment issue as a provider dispute.
If the provider does not dispute the overpayment, the provider of services must reimburse Health Net within 30 business days from the receipt of Health Net's notice, or, as permitted by law, interest begins to accrue at the rate of 10 percent per year beginning with the first day after the 30 business day period.
- Include a copy of the RA and EOP that accompanied the overpayment or the refund request letter to expedite Health Net's adjustment of the provider's account. If neither of these documents are available, the following information must be provided: member name, date of service, payment amount, Health Net member ID number, vendor name and number, provider tax ID number, provider number, and reason for the overpayment refund. If the RA and EOP are not available, it may take longer for Health Net to process the overpayment refund.
- Send the overpayment refund and applicable details to the Health Net Overpayment Recovery Department. If a provider is contacted by a third-party overpayment recovery vendor acting on behalf of Health Net, such as AIM, Rawlings, GB Collects, or ORS, the provider should follow the overpayment refund instructions provided by the vendor.
Health Net may recoup uncontested overpayments by offsetting overpayments from payments for a provider's current claims for services if:
- The provider's Provider Participation Agreement (PPA) authorizes it to offset overpayments from payments for current claims for services.
- Otherwise permitted under state laws.
A written notification is sent to the provider of service if an overpayment is recouped through offsets to claim payments. The notification identifies the specific overpayment and the claim ID number.
Hospital Overpayments
If Health Net has incorrectly paid a hospital as the primary rather than as the secondary carrier, attach a copy of the primary carrier's Explanation of Benefits (EOB) with a copy of Health Net's RA and EOP highlighting the incorrect or duplicate payments and include a check for the overpaid amount. Also include a written explanation indicating the reason for the refund (for example, other coverage, duplicate or other circumstances). Send the overpayment refund and applicable details to the Health Net Overpayment Recovery Department.