Retroactive Denial of Claims/Recoupment

Section 15-1008 of the Insurance Article limits when a carrier may retroactively deny reimbursement of a health claim that has already been paid to the provider. In general, a carrier is limited to six months from the date a claim is paid to retroactively deny the claim.

If the retroactive denial is due to fraud or miscoding, there is no time limit for the denial. If the retroactive denial is due to coordination of benefits, the time limit is 18 months from the date of payment, and the carrier must give notice that includes the primary carrier’s name and address. In a case involving a coordination of benefits, you have six months to file the claim with the primary carrier.

A carrier can reimburse itself by reducing future payments owed to a provider if the carrier provides timely notice of the retroactive denial.

To file a complaint about retroactive denial of claims, you can use our online system.