Overpayment Recovery Procedure

Cigna Behavioral Health shall not be required to correct a payment error to a professional if the professional's request for a payment correction is filed more than eighteen (18) months after the date the professional received payment for the claim from Cigna Behavioral Health.

Except in cases of fraud committed by a professional, Cigna Behavioral Health may only retroactively deny reimbursements to the professional during the eighteen (18) month period after the date Cigna Behavioral Health paid the claim submitted by the professional.

If Cigna Behavioral Health retroactively denies reimbursement to a professional, Cigna Behavioral Health will provide to the professional a written or electronic statement specifying the basis for the retroactive denial. The statement shall include, at a minimum:

1. The amount of the recovery;
2. The name of the participant to whom the recovery applies;
3. Participant identification number;
4. Date(s) of service;
5. The service(s) on which the recovery is based; and
6. The pending claims being recovered or that future claims will be recovered.

If Cigna Behavioral Health determines that payment was made for services not covered under the participant’s benefit plan, Cigna Behavioral Health shall give written notice to the professional of its intent to retroactively deny a previously paid claim and may:

1. Request a refund from the professional; or
2. Make a recovery of the payment from the professional as outlined in items 1-6, above.

The written notice may be included in the results of an audit submitted to the professional.

Except in cases of fraud committed by the professional, if Cigna Behavioral Health or an agent contracted to provide eligibility verification verifies a participant's eligibility for benefit under a plan, and the professional provides services to the participant in reliance on such verification, Cigna Behavioral Health may not thereafter retroactively deny a claim on the basis that a participant is not eligible for benefit unless such retroactive denial occurs within six (6) months of the date Cigna Behavioral Health considered the claim for benefit.

If Cigna Behavioral Health chooses to recover from a professional amounts previously paid under a retroactively denied claim, Cigna Behavioral Health shall provide the professional with written documentation that specifies:

1. The amount of the recovery;
2. The name of the participant to whom the recovery applies;
3. Participant identification number;
4. Date(s) of service;
5. The service(s) on which the recovery is based; and
6. The pending claims being recovered or that future claims will be recovered.