The Payment Recovery Program (PRP) allows Blue Cross and Blue Shield of Montana (BCBSMT) to recoup overpayments made to BCBSMT contracting facilities and providers when payment errors have occurred. BCBSMT and/or the provider may identify overpayments.
Examples of overpayment reasons include:
- Claim was paid incorrectly, as per the provider's contract
- Provider posted a credit for supplies or services not rendered
- Provider cancelled charge for any reason
- C.O.B. Credit or Duplicate Payment received by provider
- "Not our Patient" — Payment received by provider that did not render services
- Medicare Eligible or Workers Compensation payment already received
Refund Request Process
When an overpayment is identified by BCBSMT, a refund request is sent to the provider (payee) explaining the reason for the request. Request for claim refund (RFCR) letters include a remittance form and return envelope.
If a telephone or written response is not received, or if the amount of the overpayment is not returned within 45 days of the refund request, BCBSMT will recover the overpayment by offsetting current claims payments by the amount due.
Details regarding the specific overpaid patient account, amount recouped and overpayment reason will appear on the paper Provider Claim Summary (PCS) or Electronic Remittance Advice (ERA), and the Uniform Payment Program (UPP) Monthly Statement, if applicable.
Electronic Refund Management
You may submit refunds online in real-time using our Electronic Refund Management (eRM) tool. The only prerequisite is registration with Availity® Essentials. Other features of eRM include:
- Electronic notification of overpayments identified by BCBSMT
- View, search, inquire, dispute, appeal a request online
- Recoupment reconciliation information
- Alternative payment options, such as pay by check or deduct from future payments
- Ability to submit unsolicited refunds
The eRM tool also includes a Claim Inquiry Resolution (CIR) function, which enables you to submit inquiries related to High-Dollar, Pre-Pay Review requests for most Host (BlueCard® out-of-area) claims (Medical Records and/or Itemized Bill) handled by BCBSMT.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSMT. BCBSMT makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.