November 30, 2021
As part of our Payment Recovery Program, Blue Cross and Blue Shield of Illinois (BCBSIL) may recoup overpayments made to BCBSIL contracted facilities and professional providers in the PPO, Blue Choice PPOSM, Blue High Performance NetworkSM (BlueHPNSM) and any of our commercial HMO product networks when payment errors have occurred. Overpayments may be identified by BCBSIL and/or the provider.
The following process is used to recover overpayments identified by BCBSIL:
- A refund request letter explaining the reason for the refund is sent to providers. It includes a remittance form and return address envelope. Contracted providers with access to our Electronic Refund Management (eRM) tool have the option to receive overpayment notifications via email.
- If we do not receive a response to our initial communication, a follow up letter/email is sent asking for payment.
- If we do not hear from the contracted provider by telephone, in writing or through eRM, or if the provider does not return the amount of the overpayment within 90 days from the date of the follow up letter, BCBSIL reserves the right to deduct any such payment from any other payment due the provider from BCBSIL.
Recoupment or offset may be requested from future payments up to 12 months after the original payment is made by BCBSIL for commercial fully insured members. The patient information and recovery amount are explained on the electronic payment summary (EPS) or paper provider claim summary (PCS). The Electronic Remittance Advice (835 ERA) will include information in a PLB segment when an overpayment is recovered by BCBSIL. If applicable, a summary will appear on the Uniform Payment Program (UPP) monthly statement.
For overpayment reason examples and other information, see our Refund Management page. Participating providers should also refer to their participating provider agreement and applicable provider manual for additional information. Questions? Call our Financial Operations area at 844-866-2583.
This 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.