South Carolina Code 38-59-250. Initiation of overpayment recovery efforts
(a) claims where a provider has received payment for the same services from another payor whose obligation is primary; or
Terms Used In South Carolina Code 38-59-250
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Contract: A legal written agreement that becomes binding when signed.
- Fraud: Intentional deception resulting in injury to another.
- Insurer: means an insurance company, a health maintenance organization, and any other entity providing health insurance coverage, as defined in § 38-71-670(6), which is licensed to engage in the business of insurance in this State and which is subject to state insurance regulation. See South Carolina Code 38-59-210
- Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
- Provider: means a physician, hospital, or other person properly licensed, certified, or permitted, where required, to furnish health care services. See South Carolina Code 38-59-210
(b) timing or sequence of claims for the same insured that are received by the insurer out of chronological order in which the services were performed.
(2) The written notice required by this section shall include:
(a) the patient’s name;
(b) the service date;
(c) the payment amount received by the provider;
(d) a reasonably specific explanation of the change in payment; and
(e) if the claim is submitted pursuant to a provider contract that includes an appeals process, the telephone number or a mailing address through which the provider may initiate an appeal, and the deadline by which an appeal must be received.
(B) An insurer may not initiate overpayment recovery efforts more than eighteen months after the initial payment was received by the provider; however, this time limit does not apply to the initiation of overpayment recovery efforts:
(1) based upon a reasonable belief of fraud or other intentional misconduct;
(2) required by a self-insured plan; or
(3) required by a state or federal government program.