02/13/2020

Overpayment for Claim Paid in Error by HIP in 2018 (Referral Obtained)-Stating AETNA was Primary

I received an overpayment notice from a coordination of benefits company Rawlings Company. It states that a claim that I was paid for on 12/21/18 was paid in error by Emblem HIP (even though I had a referral from HIP). They are stating that Aetna was the primary and HIP paid in error. This is now 14 months, I'm pretty sure Aetna is not going to pay, what to do? Thanks

The payment is going to have to be refunded to Emblem Health, unless proof can be given that the patient was not covered by Aetna as primary on the DOS. If an eligibility statement from the insurances website, or patient call to member services can confirm that the patient did not have OHI on the DOS, no money needs to be refunded to HIP.  If Aetna is primary, the money will have to be refunded and the claim needs to be refiled to the correct insurance, where it will be denied for timely filing. At which point an appeal would be needed with the initial payment and subsequent correspondence from Emblem Health to show that the claim was not submitted timely due to a coordination of benefits issue by the patient because the practice was not given information about all active policies for the patient on the DOS.  If at that point you do not get paid then you need to bill the patient.