What would you like to do?
Texas Prompt Pay Law - Time Limitation (TAC 21.2818)
- 180 Day Limit: This applies only to claims subject to the Texas prompt pay law (enacted under Senate Bill 418) and were originally paid under SB 418 provisions. If 180 days have lapsed from the date payment was received, no refund is due
- Application: In general, the Texas prompt pay law applies to fully insured HMO and preferred provider organization products licensed and sold in Texas. It does not apply to other plans, i.e., Medicare, Medicaid, workers' compensation, TriCare, self-funded employer ERISA plans, state and federal employee plans, indemnity policies, and out-of-state Blue Cross plans (BlueCard) filed to Blue Cross and Blue Shield of Texas.
- Effective Date: The Texas prompt pay law applies to any contracts that were new or renewed on or after Aug.16, 2003. To determine if SB 418 applied when the original claim was paid, check the date or renewal date of the contract with that particular carrier; the effective date of the Texas prompt pay law will vary by payer.
- Prior Claims: For claims paid before enactment of SB 418, the time limit for refunds is based on individual contractual agreements. (Read your contract language and/or other carrier publications.)
- Automatic Recoupments: Carriers must first send a written refund request before automatically recouping money from current payments. After 45 days, if the carrier does not receive the refund or a written appeal, it can recoup the refund from any current payment.
- Noncontracted Physicians: The 180-day limit applies to claims paid on or after Aug. 16, 2003, and are subject to SB 418 provisions).
- Verification: Verification, as defined in the Texas prompt pay law, is the ONLY guarantee of payment that a payer cannot recoup later. "Preauthorization" or simply "obtaining/verifying benefits" is not a guarantee.
- Self-Funded Employer ERISA Plans - Time limits are based on individual contractual agreements. Nothing prevents carriers from automatically recouping refunds from current or future payments, regardless if the physician is contracted or noncontracted.
- Medicare Overpayments - In general, there is no practical time limit after which Medicare cannot ask for money back. TrailBlazer Health Enterprises, the Medicare carrier for Texas, is required by contract to pursue refunds on overpayments. Automatic recoupments from current and/or future payments are permitted.
- Medicaid Overpayments - In general, Medicaid may request refunds for up to five years. Depending on the circumstances, this time frame can be exceeded.
- Civil Practice and Remedies Code §16.004 - In rare situations where no contract language governs refunds and SB 418 does not apply, the statute of limitations is four years (excluding government programs).
- Preauthorization - For all payer types, preauthorization pertains only to medical necessity and is never a guarantee of payment.
- Wrongful Retention - A physician should never retain any amount truly not owed to the practice. Wrongful retention of an overpayment is called "conversion" and is illegal. If the practice did not perform the service(s), or if the reimbursement is clearly more than the plan owes, the practice should return the overpayment.
2 people found this useful
Was this answer useful?
Thanks for the feedback!
Answer Depending on where you are (I can only speak for the U.S.), there may be no restriction on how long insurance has to act on a claim. Some states to have a… statutory limit for responding to a claim (for example, ten working days) and others, like Florida, do not. They allow market forces, such as auto repairers and customers, to force action. In most states, the funny part is, you have a statutory limit on how long you have to FILE a claim. Quaint, isn't it?
Yes, you can cancel any policy at any time, and expect a refund for the used portion of premium paid.
FILING DEADLINE to get a TAX REFUND I'm answering this question; since, I asked it and want to know. I called the IRS, at 1 (800) 829-1040 [what a coincidence, ten-fort…y]. Eventually I got a real live person, and she connected me to another real person in the Filing Area (both were extremely pleasant and helpful). She was kind enough to give me the publication number 17, Chapter 1, and page 18. Which I was able to download from the IRS website http://www.irs.gov/formspubs/index.html. Anyway, I took her word for it, that it was 3 years (with exceptions) form the filing deadline. But I also found out, that the NYS Tax has the same time limitation, 3 years, that was according to a young lady at the NYS Tax line at 1 (800) 443-3200. Ans A claim for refund or credit for an overpayment must be filed within either of two periods: three years after the return to which the overpayment relates was filed or two years after the tax was paid, whichever period expires later. If the taxpayer does not file a return, any claim must be filed within two years after the time the tax was paid. If the taxpayer and the IRS agree to extend the time for assessment, the period for filing a refund claim is extended for the same period. A return for purposes of computing the filing period for refunds and credits is the return required to be filed by the taxpayer. Returns of any person from whom the taxpayer received an item of income, gain, loss, deduction or credit do not determine whether a refund claim is timely. This provision applies to tax years starting after August 5, 1997. Form 4868, Application for Automatic Extension of Time To File U.S. Individual Income Tax Return, and Form 2688, Application for Additional Extension of Time To File U.S. Individual Income Tax Return, are not considered tax returns for this purpose. The two- and three-year periods for filing a claim do not run during any period in which the individual is financially disabled. An individual is financially disabled when the individual is unable to manage his financial affairs because of a medically determinable physical or mental impairment that is expected to result in death or last for a period of at least 12 months. The physical or mental impairment must be that of the taxpayer, not of some third person The IRS may require proof of the impairment in a form and manner determined by the IRS. An individual is not financially disabled during any period that the individual's spouse or any other person is authorized to act on behalf of the individual in financial matters. These rules generally apply to all periods of disability but do not apply to any claim for credit or refund that is legally barred as of July 22, 1998. A legally barred claim includes one that is barred by res judicata. The determination of whether a claim is barred is made without regard to the tolling provision for financial disabilities.
What is the time limited if a deceased one has made an overpayment to the IRS can one request a refund?
The later of: 1. Three years after the tax return was originally due (including extensions) 2. Two years from the date the payment was made
What is the statute of limitations that an insurance company can ask for a re-imbursement for an overpayment of a claim on a HOA community?
The community received more money than the claim as the membership was able to repair some of the damages instead of using outside contractotrs. This took place 3 years …ago. Does the insurance company have the right to request the overage be returned to them??
I cancelled my home insurance with one company and opened a new policy with a different company but had overlapping coverage for a short time am I entitled to a refund.?
It depends on whether you have a mortgage loan or not. The previous insurance company will send you a check for the excess amount paid to them, but if there is a lien on your …property and your insurance check is set up in an escrow account, then you will have to sign and forward that check to your lender. That money will then go into the escrow account and sit there until the lender does a yearly evaluation and sees that your escrow account has an excess amount of money in it. Then you will get a refund on your overpaid insurance premiums. I am going through the exact same thing right now as I have just recently switched companies myself.
the standard policy says two years
If your insurance company requests a refund from your dentist because your insurance cancelled is the dentist required to send the refund?
The only time the dentist is required to refund the insurance company, is after the specific company has already made payment to the dental office and inadvertently was …an overpayment for services renderred. In the event that the dentist is a participating provider with the insurance company and has other patients with the same plan, the insurance company reserves the right to deduct the overpayment from any future payments owed to the dental office whether it is for the same patient or not.
What is the time limit for TriCare to reimburse or do a recoupment for overpayment if they had already send the check on Oct2008?
This question can only be answered by asking the State Insurance Commission in your particular state. The rules under which insurance comapnies do business in any state are se…t by that particular state.
what is the time limit for bcbs to come back and ask for overpayments made to providers
No. Pursuant to recent federal law, a plan can only go back five years from the payment date to request a refund.
The broad answer is "Yes". All causes of action have applicable statutes of limitations within which they must be commenced (filed). The sometimes difficult part is calculatin…g the limitations period. That said, all limitations period are defined by statute (written law). In general, if the suit is based upon the failure of your own insurer to pay (what you believe to be) a valid insurance claim, the suit must be brought within the time period specified by statute for suits on a written contract (the insurance policy). Alternatively, if the applicable state law prescribes a different specific period of time for suing your own insurer for nonpayment of a claim, suit must be filed within that period. Important to note is that the insurer has no duty to pay a claim until and unless the claimant has complied with all conditions specified in the policy, such as filing a proof of claim, allowing the insurer to inspect the damaged property, and the like. Some causes of action against ones own insurer are purely statutory in nature, such as those for "bad faith". These relate essentially to the manner in which the insurer has treated you in the claims process. There is generally a different statute of limitations for these (often based upon tort, rather than contract).
If you received money that you were not entitled to and you deposited the insurance check into your bank account and the money was a payout from an insurance claim, the insura…nce company can swipe the money out of your account without your prior knowledge for up to 3 years. If you received money as a result of a criminal act, the statute of limitations for that crime would guide the insurance company's timeline.
Is there a statute of limitations for dental claims in which the insurance company can request a refund of overpayment on a claim?
Ordinarily, the insurer makes payment directly to the dentist, especially if it is a managed care type of claim. Therefore, the time limit for recovering an overpayment will b…e specified in the contract between the insurer and the provider. However, if the insurer reimbursed you after you paid the dentist, your insurance contract may specify the process and time limit for the recovery of overpayment. If it does not, the law of the state in which you reside, or where the policy was issued, will specify a Statute of Limitation for breach of contract claims.
Sure. If for some reason you were overpaid for a claim the company can expect you to return the overpayment. I really don't see how this could have occurred unless you int…entionally did something to cause it to be done.