The following information does not apply to government programs (Medicare Advantage, Illinois Medicaid). It is provided as a general resource to providers regarding the overpayment recovery process that may be available for commercial claims. Participating providers should refer to their participating provider agreement and applicable provider manual for additional information.
The Payment Recovery Program (PRP) allows BCBSIL to recoup overpayments made to BCBSIL contracting facilities and providers when payment errors have occurred. Overpayments may be identified by BCBSIL and/or the provider.
Examples of overpayment reasons include:
- Claim was paid incorrectly, as per the provider’s contract
- Provider posted a credit for supplies or services not rendered
- Provider cancelled charge for any reason
- C.O.B. Credit or Duplicate Payment received by provider
- “Not our Patient” – Payment received by provider that did not render services
- Medicare Eligible or Workers Compensation payment already received
When an overpayment is identified by BCBSIL, a refund request is sent to the provider (payee) explaining the reason for the request. Request for claim refund (RFCR) letters include a remittance form and return envelope.
- If a response is not received from the payee, a follow-up letter is sent.
- If a telephone or written response is not received, or if the amount of the overpayment is not returned within 30 days of the follow-up letter date, BCBSIL will recover the overpayment by offsetting current claims payments by the amount due.
- Details regarding the specific overpaid patient account, amount recouped and overpayment reason will appear on the paper Provider Claim Summary (PCS) or Electronic Remittance Advice (ERA), and the Uniform Payment Program (UPP) Monthly Statement, if applicable.
Electronic Refund Management
- Electronic notification of overpayments identified by BCBSIL
- View, search, inquire, dispute, appeal a request online
- Recoupment reconciliation information
- Alternative payment options, such as pay by check or deduct from future payments
- Ability to submit unsolicited refunds
The eRM tool also includes a Claim Inquiry Resolution (CIR) function, which enables you to submit a variety of online requests for reconsideration on finalized claims.
Manual (Paper) Refund Processing
Institutional providers must use the eRM tool to submit refunds to BCBSIL. Professional providers without eRM access may submit refunds to BCBSIL by mail.
A Provider Refund Form must be submitted with your payment and remittance form to BCBSIL, Refund and Recovery, P.O. Box 94075, Palatine, IL 60094-4075.
- For more details, along with sample forms, letters, PCS and EPS, and related documents, see the Billing and Reimbursement section of the BCBSIL Provider Manual.