Overpayment Recovery

The adjustment process outlined below applies to physicians, other health care professionals and facilities. Please reference your Regence participating agreement to verify the adjustment process.

Payments are occasionally recouped due to a duplicate or adjusted claim. Regence does not initiate overpayment recovery efforts more than 18 months after the claim is paid. If a provider suspects a claim has been overpaid, Washington State law allows certain provider types 24 months to initiate a refund. The law allows providers 30 months to request a recoupment due to coordination of benefits (COB), or 24 months to request a recoupment for any other reason.

Washington State law requires prior written notification when a recoupment is requested by the health plan or by the provider.

• Recoupment requests for Medicare, Medicare Supplement, Healthy Options/State Children's Health Insurance Plan (SCHIP) and Federal Employee Program (FEP) members follow our current automatic deduction process for refunds.
• The legislation does not pertain to hospitals, laboratories, durable medical equipment (DME) and/or home medical equipment (HME) providers.

Note: No time limit shall apply to the initiation of overpayment recovery efforts based on any of the following criteria:

• Required by a Self-Insured Plan
• Required by a state or federal government program
• Reasonable belief of fraud or other intentional misconduct

Notification process
Regence will notify providers on the applicable remittance advice (voucher) of an impending recoupment. The notification will include the following details:

• Dollar amount
• Applicable claim number(s)
• Reason for the recoupment

Responding to a recoupment request
Once you have been notified of the recoupment, your office will have 30 days to respond. To expedite the refund process, please respond immediately. If we do not receive a response after 30 days, the recoupment will be released and automatically deducted on a future remittance advice. You may use one of the options below to respond to the recoupment request.

To refund the overpayment to Regence:

• Complete a Refund Notification (PDF) form and mail it with your refund check to the address below:

Regence BlueShield
PO Box 3016
Tacoma, WA 98401-3016

Always attach a copy of the payment voucher, overpayment recovery request or other carriers’s Explanation of Benefits (EOB) and send separate checks for:

• Regence (includes BlueCard^®)
• Regence MedAdvantage
• Federal Employee Program (FEP)

To request a deduction to a future voucher:

• Complete our online Overpayment/Voucher Deduction Request form:

• For Boeing members
• For all other members

• Print and fax or mail a completed Overpayment/Voucher Deduction (PDF) form to one of the addresses listed below.

If your office needs additional time to refund the amount due, use one of the following options to make payment arrangements:

• Contact Customer Service
• For Boeing members choose the appropriate Boeing Plan
• Mail correspondence to the appropriate address above

If you have a question regarding the original claim related to the recoupment request, please access Provider Center to view a remittance advice or check claim status.

Appealing a recoupment request
If a provider wishes to appeal a refund request initiated by Regence, they may submit an Adverse Determination Appeal within the same timeframe as other Adverse Determination Appeals as listed in the Appeals section of our Administrative Manual. Note: The timeframe begins when the provider receives the written request.

Other Links

• Contact information
• Sample Pend Report (PDF)

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