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Refunds/Recoupments
Q. Is there a limit to how far back BCBSTX will request a refund?
A. As of August 16, 2003, for those groups or accounts subject to Texas Prompt Pay Legislation, BCBSTX is limited to 180 days from the date payment is received in your office. For our self-funded Administrative Services Only (ASO) agreements, it is contingent upon the group’s guidelines and notification to BCBSTX.
Q. Where do I send voluntary refunds?
A. Refunds should be submitted using the Provider Refund Form found on our provider Web site, and sent to the address found in the upper left hand corner of that form.
Q. Can a provider notify BCBSTX of an overpayment and request a recoupment?
A. Yes. The provider may fill out the Provider Refund Form. Instead of issuing a refund, you may request an offset (recoupment) on the form at the time of notification. You will receive a confirmation in the form of a refund request letter shortly preceding the actual offset (recoupment).
Q. Why do we have to suffer denial of payment when BCBSTX retroactively terminated eligibility on the patient’s plan when we confirmed eligibility and benefits at the time we provided services?
A. We are reviewing our current membership processes and working with our employer groups to update their eligibility information as quickly as possible. Unfortunately there are occasions for which BCBSTX may process a retroactive termination. Please keep in mind that BCBSTX provides the most current information possible at the time of each inquiry. In addition, if the member is subject to Texas Prompt pay Legislation you may request a Verification which is a guarantee of payment regardless if their coverage changes retroactively.
Q. Why does BCBSTX take money from another patient’s payment?
A. Recoupments cannot always be applied to the same patient for which the overpayment applies. To avoid a recoupment, you may refund the balance due by following the instructions found in the notice you receive.
Q. Why do we not always receive a reason for the refund request?
A. Process improvements have recently been made in this area and you should now be receiving more detailed information in your refund request notices.
Q. Is there a limit on refund amounts, (i.e. 50 cents)?
A. Generally BCBSTX will not request refunds on individual claims where the paid amount is $50.00 or less. However, if we identify that an overpayment was made on more than one claim, even though the amount owed on each is less than $50.00 if the total amount owed is greater than $50.00, we will request a refund for each individual claim. This may differ for our self-funded Administrative Services Only (ASO) agreements. Refunds are requested for HMO Blue Texas claims regardless of the amount. At the request of the physician/provider, refunds will be processed for any amount owed.
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