Recoupment limits by state: how far back a payer can reach, and the notice it owes

An insurer, health service corporation, and health benefit plan shall not retroactively deny, adjust, or seek recoupment or refund of a paid claim for health care expenses submitted by a health care provider for any reason, other than fraud or coordination of benefits or for duplicate payments on claims received from the same insurer, health service corporation, or health benefit plan for the same service, after the expiration of one year from the date that the initial claim was paid or after the expiration of the same period of time that the health care provider is required to submit claims pursuant to a contract between the health care provider and an insurer, health service corporation, or health benefit plan, whichever date occurs first.

Lookback: 12 months from the paid date. Exceptions: fraud, coordination of benefits, duplicate payment (on claims received from the same insurer/HSC/plan for the same service). Provider’s right to contest: Provider who disputes/contests a retroactive denial, adjustment, or recoupment/refund request must notify the insurer within 30 days after receiving the insurer's notice. Any contract provision in conflict with the section is unenforceable.

Alabama's 1-year recoupment window can be cut shorter: if a provider's payer contract requires claims to be filed in under a year, that same shorter period also caps how far back the insurer can recoup.

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A health care insurer shall give written notice to a health care provider, health care facility, or consumer at least 30 calendar days before the insurer seeks recovery of an overpayment. The notice must include adequate information for the health care provider, health care facility, or consumer to identify the specific claim and the specific reason for the recovery. A health care insurer may not initiate recovery of an overpayment more than 365 days after the date the original payment was made to a health care provider, health care facility, or consumer, or its agents, unless the health care insurer has clear and documented reason to believe that the health care provider, the health care facility, or consumer, or its agents has committed fraud or other intentional misconduct.

Lookback: 12 months from the paid date. Notice: 30 days. Offset against other claims: permitted. Exceptions: fraud or other intentional misconduct (with clear and documented reason). Provider’s right to contest: 3 AAC 26.110(e): insurer must provide the provider/facility/consumer an opportunity to challenge the recovery of an overpayment, including sharing of claims information, under written policies/procedures the insurer establishes.

Alaska regulates private-insurer recoupment under Division of Insurance rule 3 AAC 26.110, not the Medicaid-only rule (7 AAC 105.260) some sources cite. Insurers must give 30 days' notice, are capped at a 1-year lookback (no cap for fraud), and can only offset the same patient's claims.

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Except in cases of fraud, a health care insurer or contracted or noncontracted health care provider shall not adjust or request adjustment of the payment or denial of a claim more than one year after the health care insurer has paid or denied that claim.

Lookback: 12 months from the paid date. Offset against other claims: permitted. Exceptions: fraud. Provider’s right to contest: §20-3102(F) requires health care insurers to maintain an internal grievance system; §20-3102(I) requires annual public reporting of grievance data and overturn rates. The statute states the director does not adjudicate individual claims/contracts.

Arizona's 1-year recoupment clock runs from the date the insurer paid or denied the claim, and it cuts both ways — providers get the same 1-year window to request their own claim adjustments, except in cases of fraud.

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Except in cases of fraud committed by a healthcare provider, a healthcare insurer may exercise recoupment from a healthcare provider only during the eighteen-month period after the date that the healthcare insurer paid the claim submitted by the healthcare provider.

As quoted by a secondary source; not checked against the state's own statute text this cycle.

Lookback: 18 months from the paid date. Offset against other claims: permitted. Exceptions: fraud committed by the healthcare provider. Provider’s right to contest: §23-63-1802(a)(2): provider may submit a corrected claim for up to 6 months after recoupment for services actually provided but billed in error without intent to defraud. §23-63-1802(b): insurer must give written/electronic statement specifying the basis for recoupment, containing at minimum the disclosures required by §23-63-1804 (amount, covered person's name, patient ID, dates of service, service(s) at issue, whether pending or future claims are being recouped, and specific reason).

Arkansas insurers can recoup a paid claim only within 18 months of payment date (no limit if provider fraud); the insurer must give written notice, and providers have 6 months after recoupment to submit a corrected claim for billing errors.

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A plan or a plan's capitated provider shall not request reimbursement for the overpayment of a claim, including requests made pursuant to Health and Safety Code Section 1371.1, unless the plan or the plan's capitated provider sends a written request for reimbursement to the provider within 365 days of the Date of Payment on the over paid claim. The 365-day time limit shall not apply if the overpayment was caused in whole or in part by fraud or misrepresentation on the part of the provider.

As quoted by a secondary source; not checked against the state's own statute text this cycle.

Lookback: 365 days from the Date of Payment on the overpaid claim (Cal. Code Regs. tit. 28, § 1300.71(b)(5)); no lookback limit if overpayment was caused by provider fraud/misrepresentation. Offset against other claims: permitted. Exceptions: fraud or misrepresentation by the provider. Provider’s right to contest: Under HSC §1371.1(a)(1), provider has 30 working days from receipt of the overpayment notice to reimburse OR contest in writing, identifying the contested portion and specific reasons; if uncontested and unpaid within 30 working days, interest accrues at 10%/year from the first calendar day after that period (§1371.1(a)(2)). Dental plan notices must also explain the plan's dispute resolution mechanism (§1371.1(b)(2)). Offset under §1300.71(d)(6) is permitted only if (i) the provider fails to reimburse within the 365-day-linked timeframe AND (ii) the provider has a written contract specifically authorizing the plan to offset an uncontested overpayment; plan must provide a detailed written explanation of what was offset against which current claim(s).

California plans must resolve an overpayment notice within 30 working days or owe 10% annual interest; a separate DMHC regulation (365-day lookback, fraud exception) governs recoupment timing but could not be confirmed at an official state site this pass.

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Adjustments to claims by the provider or the carrier shall be made within the time period set out in a contract between the provider and the carrier. Such time period shall be the same for the provider and the carrier and shall not exceed twelve months after the date of the original explanation of benefits.

Lookback: 12 months from the paid date. Exceptions: fraud or abuse committed by the provider and reported by the carrier under §10-1-128(5)(a)(IV) — exempt from the 12-month cap entirely. Provider’s right to contest: §10-16-704(4.5)(l)(I): any carrier adjustment recovering overpayments must include written notice to the provider (and to the enrollee if it affects enrollee liability) with 'a complete and specific explanation of such adjustments and information regarding the carrier's provider dispute resolution procedures.'.

Colorado caps most claim adjustments/recoupments at 12 months after the EOB, and a provider contract can only shorten — never lengthen — that window; coordination-of-benefits with Medicare/Medicaid gets 36 months, and carrier-reported provider fraud has no cap.

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No contracting health organization shall cancel, deny or demand the return of full or partial payment for an authorized covered service due to administrative or eligibility error, more than eighteen months after the date of the receipt of a clean claim, except if:

Lookback: 18 months from receipt of the clean claim. Notice: 30 days. Exceptions: fraud (documented basis to believe the claim was submitted fraudulently), inappropriate billing (provider did not bill appropriately based on documentation of the service actually provided), duplicate payment (organization paid the provider more than once), payment that should have been paid by a federal or state program, coordination of benefits/subrogation/auto-insurance/workers'-comp (provider was paid by a different insurer/payor/administrator). Provider’s right to contest: Provider has 30 days after receiving the notice to appeal; 'Any demand for the return of full or partial payment shall be stayed during the pendency of such appeal.' If no appeal is filed or the appeal is denied, the provider may resubmit an adjusted claim within 30 days, and has up to 1 year to identify other applicable insurance coverage and file a secondary claim.

CT insurers must give 30 days' written notice and generally can't demand repayment more than 18 months after a clean claim is paid, with 5 exceptions (fraud, bad billing, duplicate payment, wrong-payer, or COB/subrogation).

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A health insurer or health plan may not initiate overpayment recovery efforts more than 12 months after the original payment for the claim was made.

Lookback: 12 months from the paid date. Exceptions: fraud, abuse, or other intentional misconduct as indicated by physical review or review of claims data/statements, recovery required by, or initiated at the request of, a self-insured plan, recovery required by a state or federal government plan. Provider’s right to contest: Insurer must provide the health-care provider an opportunity to challenge an overpayment recovery, including sharing of claims information, and must establish written policies/procedures for providers to follow to challenge a recovery.

Delaware's overpayment lookback was cut from 24 to 12 months effective 2025-09-03. Duplicate-payment recoupments skip the written-notice step but still must happen within 12 months. Audits can't use extrapolation/projected overpayments. Medicaid plans are excluded.

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No statute text could be opened for this state this cycle.

No DC statute governs insurer recoupment from providers. DC's insurance regulations (DCMR Title 26) and DISB bulletins have not yet been checked for a rule — this is an open gap, not a confirmed absence.

All claims for overpayment must be submitted to a provider within 30 months after the health insurer's payment of the claim.

Lookback: 30 months from the paid date. Offset against other claims: permitted. Exceptions: fraud (provider convicted under s. 817.234) — no time limit. Provider’s right to contest: Provider must pay, deny, or contest the overpayment claim within 40 days of receipt; if contesting, must notify the insurer in writing within 35 days that the claim is contested/denied; insurer then has 35 days to furnish supporting information; provider has 45 days after receiving that information to pay or deny; all contested overpayment claims must be resolved within 120 days of the provider's receipt of the original claim, and failure to pay or deny within 140 days creates an uncontestable obligation (i.e., the insurer's overpayment claim fails).

Florida gives insurers 30 months to recoup (12 months for physicians/dentists/chiropractors/podiatrists); no time limit for provider fraud. Insurers can't offset future payments unless you agree or don't respond within 40 days. HMOs (ch. 641) follow an identical rule.

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No carrier, plan, network, panel, or any agent thereof may conduct a postpayment audit or impose a retroactive denial of payment on any claim submitted by a provider or facility more than 90 days after the date of service unless the carrier, plan, network, or panel first provides written notice.

As quoted by a secondary source; not checked against the state's own statute text this cycle.

Lookback: For claims submitted within 90 days of the date of service: the carrier must give written notice of intent to audit within 12 months after the last date of service, and must complete the postpayment audit/retroactive denial (with notice of any payment or refund due) within 18 months after the last date of service. For claims first submitted more than 90 days after the date of service: the 12-month notice window instead runs from the date of claim submission, and completion is required within the earlier of 18 months after submission or 24 months after the date of service. Exceptions: precertified claims cannot be reopened/contested at all after precertification, except where the insurer is not liable under §33-20A-7.1.

Georgia carriers must notify you within 12 months of service (or claim submission) and finish any postpayment audit within 18-24 months; precertified claims can't be reopened at all once approved, except for eligibility issues.

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(i) Prior to initiating any recoupment or offset demand efforts, an entity shall send a written notice to a health care provider at least thirty calendar days prior to engaging in the recoupment or offset efforts. ... Any appeal of a recoupment or offset shall be made by a health care provider within sixty days after the receipt of the written notice. (j) An entity shall not initiate recoupment or offset efforts more than eighteen months after the initial claim payment was received by the health care provider or health care entity

Lookback: 18 months from the paid date. Notice: 30 days. Offset against other claims: permitted. Exceptions: fraud or material misrepresentation (lookback extends to 72 months instead of 18), self-insured employer groups (no time limit), services rendered to individuals through a national participating provider network (no time limit), Medicaid, Medicare, Medigap, or other federally financed plan claims (no time limit), claims involving coordination of benefits, subrogation, preexisting-condition investigations, or third-party liability (not bound by the 18-month limit). Provider’s right to contest: Provider may appeal a recoupment or offset within 60 days after receipt of the written notice. The notice itself must prominently display: the patient's name, date of service, and payment amount; the reason for the recoupment/offset; and the telephone number or mailing address through which the provider may initiate an appeal, along with the appeal deadline.

Hawaii insurers must give 30 days' written notice before recouping and can't reach back more than 18 months (72 months for fraud). No lookback limit at all for self-funded, national-network, or Medicare/Medicaid claims. You have 60 days to appeal.

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No statute text could be opened for this state this cycle.

Idaho has no state law limiting how far back a commercial/HMO insurer can recoup a provider overpayment, require notice, or restrict offsetting future claims — none was found in Idaho Code Title 41.

No statute text could be opened for this state this cycle.

Illinois has no statute setting a recoupment lookback, notice period, or offset limit for insurer recovery of provider overpayments — none found in the Illinois Insurance Code (Art. XXVI) or the Managed Care Reform and Patient Rights Act.

An insurer may not, more than two (2) years after the date on which an overpayment on a provider claim was made to the provider by the insurer: (1) request that the provider repay the overpayment; or (2) adjust a subsequent claim filed by the provider as a method of obtaining reimbursement of the overpayment from the provider.

As quoted by a secondary source; not checked against the state's own statute text this cycle.

Lookback: 24 months from the paid date. Offset against other claims: permitted. Exceptions: fraud by the provider, the insured, or the insurer with respect to the claim.

Indiana bars recoupment starting more than 2 years after the overpayment was paid, with no time limit for fraud. The insurer must explain the overpayment in writing when adjusting a later claim to collect it, but no fixed advance-notice period is set in days.

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Absent a reasonable basis to suspect fraud, an insurer may not audit a claim more than two years after the submission of the claim to the insurer.

Lookback: 24 months from submission. Exceptions: fraud (reasonable basis to suspect fraud removes the 2-year audit limit), claims with billed charge under $25 (also exempt from the 2-year limit).

Iowa has no recoupment-specific law, but insurers can't audit a paid claim more than 2 years after you submitted it (unless fraud is suspected or the claim is under $25) — Insurance Division Rule 191-15.33, amended 4/24/24.

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No statute text could be opened for this state this cycle.

Except in cases of fraud, an insurer may only retroactively deny reimbursement to a provider during the twenty-four (24) month period after the date that the insurer paid the claim submitted by the provider.

Lookback: 24 months from the paid date. Exceptions: fraud — no time limit. Provider’s right to contest: Where a retroactive denial results from coordination of benefits, the provider has 12 months from the date of receiving the denial notice to submit the claim to the entity the insurer identifies as responsible for payment. General retroactive-denial notice must be a written or electronic statement specifying the basis for the denial; if COB-related, it must also name the entity acknowledging responsibility for payment.

Kentucky's 24-month recoupment window runs from the date the insurer paid the claim, not the date of service — and providers get 12 months to rebill after a coordination-of-benefits denial (KRS 304.17A-708).

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A health insurance issuer shall not retroactively deny, adjust, or seek recoupment or refund of a paid claim for healthcare expenses submitted by a healthcare provider for healthcare services rendered in good faith and pursuant to the benefit plan for any reason after the expiration of eighteen months from the date the initial claim was paid.

As quoted by a secondary source; not checked against the state's own statute text this cycle.

Lookback: 18 months from the paid date. Notice: 30 days. Offset against other claims: permitted. Provider’s right to contest: Provider has 30 days from receipt of the issuer's written recoupment notice (patient name, dates of service, reason) to appeal with its own explanation; no timely written response is deemed acceptance of the recoupment. If disputed and a provider contract exists, resolved per that contract's dispute-resolution clause; if no contract, resolved as a civil dispute under La. Civil Code art. 2299 et seq. (unjust enrichment).

18-month cap runs from date of payment and never overrides a shorter deadline set elsewhere in law; does not apply to the state's Office of Group Benefits plan (La. R.S. 22:1838(G)).

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a carrier ... may not impose on any provider any retrospective denial of a previously paid claim ... unless the carrier has provided the reason ... in writing to the provider and the time that has elapsed since the date of payment of the previously paid claim does not exceed 12 months.

Lookback: 12 months from the paid date. Offset against other claims: permitted. Exceptions: fraud, duplicate payment (provider/insured already paid), services not delivered, coordination of benefits / another payor, claim subject to legal action, Medicare/Medicaid/CHIP claims (no limit). Provider’s right to contest: Carrier must give the provider a written statement of the reason for the retrospective denial. Providers reportedly have roughly 6 months from notification to verify/dispute whether other coverage applied (COB scenario) -- verify exact figure/subsection before relying on it.

Tiered, not a flat cap: any reason within 12 months; 4 specific reasons from 12-36 months; fraud and Medicare/Medicaid/CHIP claims have no time limit at all.

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a carrier may only retroactively deny reimbursement during the 6-month period after the date that the carrier paid the health care provider

Lookback: 6 months from the paid date. Exceptions: fraud, improper coding (carrier must have given 30 days' advance notice of its coding guidelines), duplicate claims, coordination of benefits (gets 18-month window instead of 6), Medicaid MCO capitation-payment retractions.

6-month cap extends to 18 months only for coordination-of-benefits denials; fraud, improper coding (with 30-day advance notice of coding guidelines), duplicate claims, and Medicaid MCO capitation retractions have no time limit.

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An insurer or other entity shall not impose a retroactive claims denial for behavioral health services on a provider unless: (i) less than 12 months have elapsed from the time of submission of the claim by the provider to the insurer or other entity

Lookback: 12 months from submission, behavioral-health services only (c.176G §6B and parallels); no general recoupment lookback statute for medical claims. Notice: 30 days. Offset against other claims: permitted. Exceptions: fraud, claim subject to legal action, duplicate payment (provider or insured already paid), services not delivered by the provider. Provider’s right to contest: Provider must receive a written explanation of the reason for the retroactive denial and is given 30 days to submit additional documentation or take other corrective action before the denial/recoupment proceeds.

Massachusetts limits retroactive denials only for behavioral-health claims. There is no statutory lookback for infusion, oncology or other medical claims; the contract governs.

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No statute text could be opened for this state this cycle.

No Michigan statute found governing insurer recoupment lookback, notice, or offset from a provider — treat any recoupment as governed only by the parties' contract.

Once a clean claim ... has been paid, the contract must provide a 12-month deadline on all adjustments to and recoupments of the payment with the exception of payments related to coordination of benefits, subrogation, duplicate claims, retroactive terminations, and cases of fraud and abuse.

Lookback: 12 months from the paid date. Exceptions: coordination of benefits, subrogation, duplicate claims, retroactive terminations, fraud and abuse, pharmacy contracts (exempt from this subdivision entirely).

The 12-month recoupment deadline is a required CONTRACT term, not a direct statutory bar, and pharmacy contracts are exempt from it entirely.

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the health insurance issuer or other health insurance benefit payer may not request reimbursement or offset another claim payment for reimbursement of an invalid claim or overpayment of a claim more than twelve (12) months after the payment of an invalid or overpaid claim.

As quoted by a secondary source; not checked against the state's own statute text this cycle.

Lookback: 12 months from the paid date. Offset against other claims: permitted. Exceptions: fraud / misrepresentation / omission / concealment, pharmacy audits (separate statute), Mississippi Medicaid claims (5-year window instead), audits opened before July 1, 2012.

Lookback mirrors whatever claim-submission deadline the payer itself imposes on providers; defaults to 12 months only if the payer sets no such deadline. Medicaid claims get 5 years instead.

An amount a health carrier claims was overpaid to a provider may only be collected, withheld, or recouped from the provider, or third party that submitted the provider's claim under the third party's provider identification number, to whom the overpaid amount was originally paid.

Offset against other claims: permitted.

No statutory time limit on when Missouri recoupment may be sought — only WHO it may be taken from (the original payee). Section was amended most recently effective 2024-08-28.

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the health insurance issuer may not request reimbursement or offset another claim payment for reimbursement of an invalid claim or overpayment of a claim more than 12 months after the payment of an invalid or overpaid claim.

Lookback: 12 months from the paid date. Offset against other claims: permitted. Exceptions: fraud (time limit paused pending commissioner review, not eliminated), coordination of benefits / other payor notice (own 12-month window), non-fraud provider error (discovery-rule clock, capped at 24 months after payment).

Effectively a 24-month hard outer cap for ordinary provider billing errors (via the discovery rule), with a separate unconditional 12-month default and COB window; both sections amended 2025.

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The contractor shall review claims within three years from the date of the payment... an overpayment shall not be recouped for at least sixty days after the date of notice of adverse findings.

Lookback: 36 months from the paid date. Notice: 60 days. Exceptions: credible allegation of provider fraud (with DHHS referral and investigation) allows recovery before appeals are exhausted. Provider’s right to contest: Overpayment may not be recouped until all appeals are exhausted, unless there is a credible allegation of provider fraud meeting statutory criteria; written notice must include the basis for the determination, payment method, appeal procedure, and recovery method (§68-974(2)(h)); no recoupment for at least 60 days after notice of adverse findings; extrapolated overpayments are barred without a sustained pattern of error, an excessively high error rate, or provider agreement.

Governs Nebraska MEDICAID MCO audits only, not commercial/fully-insured plans. No general commercial recoupment statute was located this pass.

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No statute text could be opened for this state this cycle.

No Nevada statute found requiring an insurer to give notice or observe a lookback before recouping a provider overpayment — treat as governed only by the provider contract.

A health carrier shall not impose a retroactive denial of a previously paid claim unless the health carrier has provided the reason for the retroactive denial in writing to the health care provider and the retroactive denial is within 12 months of the date the initial claim was paid.

Lookback: 12 months from the paid date. Notice: 15 days. Offset against other claims: permitted. Exceptions: claim submitted fraudulently, provider or insured already paid for the services identified in the claim (duplicate payment), health care services identified in the claim were not delivered by the provider, claim payment was for services covered by Medicare/Medicaid/CHIP (Title XVIII, XIX, or XXI), claim payment is the subject of an adjustment with a different, unaffiliated insurer/administrator/payor, claim payment is the subject of a pending legal action. Provider’s right to contest: Carrier must notify the provider at least 15 days in advance of imposing a retroactive denial; under the version effective 2027-01-01, if the provider appeals within that 15-day window, recoupment may occur only after the appeal and external review process concludes. 'Retroactive denial' is defined broadly to include requiring repayment, reducing other payments owed, or withholding/offsetting against future payments.

Notice is 15 days, not 30. Starting 2027-01-01 a timely provider appeal blocks recoupment until the appeal and external review conclude.

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No statute text could be opened for this state this cycle.

Lookback: 18 months from the paid date. Exceptions: fraud, provider pattern of inappropriate/abusive billing, coordination of benefits. Provider’s right to contest: Secondary source states payers must provide written documentation identifying the specific processing/payment error when requesting reimbursement, and that a payer cannot seek more than one reimbursement for the same overpayment; not independently confirmed against primary text.

UNCONFIRMED against primary text — the 18-month figure and exceptions come from a secondary mirror only. Do not cite as authoritative until N.J.S.A. 17B:30-48 itself has been opened.

No statute text could be opened for this state this cycle.

No New Mexico recoupment statute confirmed either way — Chapter 59A Article 22 (Health Insurance Contracts) has not been fully reviewed. Treat as unknown, not as "no law."

A health plan shall not initiate overpayment recovery efforts more than twenty-four months after the original payment was received by a health care provider... a health plan shall provide thirty days written notice to health care providers before engaging in additional overpayment recovery efforts.

Lookback: 24 months from the paid date. Notice: 30 days. Offset against other claims: permitted. Exceptions: fraud or intentional misconduct, abusive billing (inconsistent billing practices at a frequency reflecting a pattern of conduct), self-insured plan (ERISA) requests, state or federal government program requirements, duplicate payments (excluded from the 30-day notice requirement). Provider’s right to contest: Health plan must give the provider an opportunity to challenge the overpayment recovery, including sharing the claims information relied on, and must establish written policies/procedures for such challenges specifying the grounds a provider may dispute. Notice must include patient name, service date, payment amount, proposed adjustment, and a reasonably specific explanation.

The 24-month cap runs against the PAYER's own recovery; if a provider disputes an underpayment, the plan may offset against overpayments further back than 24 months to answer it.

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Subject to the time lines required under this section, the insurer may recover overpayments made to the health care provider or health care facility by making demands for refunds and by offsetting future payments.

Lookback: 24 months from the paid date. Notice: 30 days. Offset against other claims: permitted. Exceptions: reasonable belief of fraud or other intentional misconduct, provider received payment for the same service from a government payor. Provider’s right to contest: Insurer must give the provider not less than 30 calendar days' written notice before seeking overpayment recovery or offsetting future payments, and the notice must contain adequate specific information to identify the specific claim and the specific reason for the recovery. Providers have a mirror-image right: they may seek recovery of underpayments/nonpayments within the same two-year window (with the same fraud/government-payor exceptions).

Cuts both ways: providers get the identical 2-year/30-day mechanism to recover underpayments from the insurer, with the same fraud/government-payor carve-outs.

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No statute text could be opened for this state this cycle.

No North Dakota statute requires notice or a lookback window before a payer recoups a provider overpayment — confirmed by full-text review of the two most likely chapters, not just an index scan.

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A payment made by a third-party payer to a provider in accordance with sections 3901.381 to 3901.386 of the Revised Code shall be considered final two years after payment is made... After that date, the amount of the payment is not subject to adjustment, except in the case of fraud by the provider.

Lookback: 24 months from the paid date. Offset against other claims: permitted. Exceptions: fraud by the provider (no time limit in that case). Provider’s right to contest: Required written notice (under the related §3901.381-.386 process) must include the beneficiary's name, service dates, overpayment amount, claim numbers, a detailed explanation of the basis for the determination, payment method, and appeal rights; provider gets 30 days to appeal before recovery may proceed if no response or the appeal is denied. Recovery may be made by offset against future payments or other remedies available under law; any contract term that conflicts with these requirements is unenforceable.

This 2-year rule is being AMENDED by Senate Bill 162, effective 2026-10-07 (about 2.5 weeks from today) — re-check the new version before citing after that date.

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Requesting a refund of all or a portion of a payment of a claim made to a claimant more than six (6) months or a health care provider more than twelve (12) months after the payment is made. This paragraph shall not apply: a. if the payment was made because of fraud committed by the claimant or health care provider, or b. if the claimant or health care provider has otherwise agreed to make a refund to the insurer for overpayment of a claim;

Lookback: 12 months from the paid date. Exceptions: payment was made because of fraud committed by the claimant or health care provider, claimant or provider has otherwise agreed to make a refund to the insurer for overpayment of a claim.

Oklahoma shortened its recoupment window effective 2025-11-01: insurers now have only 12 months (was 18) to recoup from a provider, 6 months (was 12) from a claimant.

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(2) Except in the case of fraud or abuse of billing, and except as provided in subsections (3) and (5) of this section, a health insurer may not: (a) Request from a health care provider a refund of a payment previously made to satisfy a claim unless the health insurer: (A) Requests the refund in writing on or before the last day of the period specified by the contract with the health care provider or 18 months after the date the payment was made, whichever is earlier; and (B) Specifies in the written request why the health insurer believes the provider owes the refund.

Lookback: 18 months from the paid date. Offset against other claims: permitted. Exceptions: fraud or abuse of billing (no time limit), coordination of benefits (extends deadline to 30 months), third-party/government entity found liable and insurer can't recover directly from that third party (no time limit). Provider’s right to contest: Provider may contest the refund request in writing; if provider does not contest within 30 days of receiving the request, it is deemed accepted. A contested refund may not be required to be paid earlier than 6 months after the provider receives the request.

Oregon caps recoupment at 18 months (30 for coordination-of-benefits cases), but a contested refund can't be collected until 6 months after the demand, and it's deemed accepted if not contested within 30 days.

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No statute text could be opened for this state this cycle.

Lookback: Multiple secondary/aggregator sources (not independently confirmed in primary text) describe a Pennsylvania rule that 'an insurer may not retroactively deny reimbursement as a result of an overpayment determination more than 24 months after the date the insurer initially paid the health care provider,' commonly attributed to Act 68 of 1998 (Quality Health Care Accountability and Protection Act). This could not be located in primary text — see notes.

Except as otherwise provided herein, any review, audit, or investigation by a nonprofit medical service corporation of a healthcare provider's claims that results in the recoupment or set-off of funds previously paid to the healthcare provider in respect to such claims shall be completed no later than eighteen (18) months after the completed claims were initially paid, except that the period for recoupment or set-off for claims submitted by a mental health and/or substance use disorder provider ... shall be no later than twelve (12) months.

Lookback: 18 months from the paid date. Offset against other claims: permitted. Exceptions: claims submitted fraudulently, claims known, or that should have been known, to be a pattern of inappropriate billing per the provider's specialty billing standards, coordination of benefits, duplicate claims, claims subject to federal law or regulation permitting review beyond the state period.

Rhode Island's 18-month (12-month for behavioral health) recoupment window applies to insurers and HMOs generally, not just Blue Cross — nearly identical language sits in three separate chapters.

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An insurer may not initiate overpayment recovery efforts more than eighteen months after the initial payment was received by the provider.

Lookback: 18 months from the paid date. Notice: 30 business days. Exceptions: duplicate payments or similar adjustments where the provider was paid by another payor whose obligation is primary, claims received out of chronological order (timing/sequence adjustments), reasonable belief of fraud or other intentional misconduct, recovery required by a self-insured plan, recovery required by a state or federal government program. Provider’s right to contest: If the claim was submitted under a provider contract that includes an appeals process, the required written notice must include the phone number or mailing address through which the provider may initiate an appeal, and the deadline by which an appeal must be received.

South Carolina's 30-day notice before recoupment is 30 BUSINESS days, not calendar days — a detail billers often miss when counting the deadline.

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Except as otherwise provided in this section, a previously paid claim may be recouped, recovered, or retroactively denied by the health carrier only within eighteen months from the date the claim payment was made, if the health carrier has provided written notice of the reason to the provider.

As quoted by a secondary source; not checked against the state's own statute text this cycle.

Lookback: 18 months from the paid date. Offset against other claims: permitted. Exceptions: claim determined by the health carrier to have been submitted fraudulently or to involve waste or abuse, adjustment with a different, unaffiliated health carrier/administrator/payor (no shared claims-payment/processing/pricing relationship), medical services covered by casualty insurance (SDCL 58-9-11 to 58-9-27), medical services covered by a self-insured ERISA health plan, medical services covered by Medicare, Medicaid, or other federal law, medical services covered by workers' compensation (SDCL Title 62), claim was incorrect because the provider or member had already been paid for the services.

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(b) A health insurance entity is not required to correct a payment error to a healthcare provider if the provider's request for a payment correction is filed more than fifteen (15) months after the date that the healthcare provider received payment for the claim from the health insurance entity. (c)(1) Except in cases of fraud or suspected fraud committed by the healthcare provider, a health insurance entity may only recoup reimbursements made to the provider during the fifteen-month period after the date that the health insurance entity paid the claim submitted by the healthcare provider.

Lookback: 15 months from the paid date. Notice: 30 days. Offset against other claims: permitted. Exceptions: fraud or suspected fraud committed by the healthcare provider (no time limit), eligibility-verification-reliance cases are capped at 6 months instead of 15/18, a receiver appointed under Title 56 Ch. 9 may audit/collect MCO overpayments more than 18 months after the MCO paid the claim (not governed by this section's limits), the bureau of TennCare may collect MCO overpayments more than 15 months out if discovered via a TennCare audit (not governed by this section's limits), a health insurance entity contracting directly with the bureau of TennCare is excluded from this section for TennCare-only products/services. Provider’s right to contest: Notice of intended recoupment must state, among other required content, the process by which the provider may appeal, including instructions (subsection (e)(1)(H)). If the provider initiates an appeal within 30 days of the notice, payment must not be withheld from the provider until all appeals are exhausted (subsection (f)).

Tennessee's recoupment window is 15 months (18 for state employee health plans, 6 for eligibility-verification-error cases) with 30 days' notice, per a 2024 rewrite (Pub. Ch. 861, eff. 2024-07-01) — extrapolation-based recoupment is banned outright.

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An HMO may recover an overpayment to a physician or provider if not later than the 180th day after the date the physician or provider receives the payment, the HMO provides written notice of the overpayment, and the physician or provider does not make arrangements for repayment of the requested funds on or before the 45th day after the date the physician or provider receives the notice.

As quoted by a secondary source; not checked against the state's own statute text this cycle.

Lookback: 180 days after the physician/provider receives the original payment (not stated as a month count in the statute); this is the deadline by which the carrier must send written notice of the overpayment, not a separate audit-lookback window. Notice: 45 days. Provider’s right to contest: If the physician or provider disagrees with a request for recovery of an overpayment, the HMO/insurer shall provide an opportunity to appeal, and may not recover the overpayment until all appeal rights are exhausted.

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(14) Nothing in this section may be construed as limiting the ability of an insurer to: (a) recover any amount improperly paid to a provider or an insured: (i) in accordance with Section 31A-31-103 or any other provision of state or federal law; (ii) within 24 months of the amount improperly paid for a coordination of benefits error; (iii) within 12 months of the amount improperly paid for any other reason not identified in Subsection (14)(a)(i) or (ii); or (iv) within 36 months of the amount improperly paid when the improper payment was due to a recovery by Medicaid, Medicare, the Children's Health Insurance Program, or any other state or federal health care program... (15) A provider may only seek recovery from the insurer for an amount the insurer improperly pays within the same time frames described in Subsection (14)(a).

Lookback: 12 months from the paid date. Exceptions: fraudulent insurance act under §31A-31-103, or recovery under other state/federal law — no time limit, coordination of benefits error — extended to 24 months, Medicaid/Medicare/CHIP or other state/federal health care program recovery — extended to 36 months. Provider’s right to contest: Each insurer must establish a review process to resolve claims-related disputes between the insurer and providers (subsection (9)). A provider may itself seek recovery from the insurer for the insurer's own improper payment, but only within the same 12/24/36-month time frames given to insurers (subsection (15)). No specific advance-written-notice-before-recoupment requirement is stated in this section (contrast VT/VA/WV, which require 30 days). The general unfair-claim-settlement-practices bar in subsection (10) — e.g. an insurer may not use a claim dispute to retaliate against or intimidate a provider, or fail to substantively respond to a provider's written communication within 15 days — applies to recoupment-related conduct generally.

Utah's recoupment window is layered by reason: 12 months for most overpayments, 24 months for coordination-of-benefits errors, 36 months for Medicaid/Medicare/CHIP recoveries, and no limit for fraud. No advance-notice-day requirement is specified in the statute.

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A health plan in this State shall not impose on any provider any retrospective denial of a previously paid claim... unless: (1) The health plan has provided at least 30 days' notice... (2) The time that has elapsed since the date of payment... does not exceed 12 months.

Lookback: 12 months from the paid date. Notice: 30 days. Exceptions: fraud or other intentional misconduct, claim payment incorrect because provider already paid for the services, services not delivered by the provider, claim payment is subject of adjustment with another health plan (COB), claim is subject of legal action. Provider’s right to contest: Statute does not spell out a formal dispute/appeal mechanism for the provider in § 9418 itself; it only conditions retrospective denial/recovery on the 30-day written notice (with patient name, service date, payment amount, proposed adjustment, and explanation) and the 12-month limit.

Routine recoveries (duplicate payments, non-member payments, non-covered services and similar) are exempt from the 30-day advance-notice requirement; the 12-month limit still applies except for fraud, COB, undelivered services or legal action.

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No carrier shall impose any retroactive denial of a previously paid claim... unless... (iii) the time which has elapsed since the date of the payment of the original challenged claim does not exceed 12 months... A carrier shall notify a provider at least 30 days in advance of any retroactive denial or recovery or refund of a previously paid claim.

Lookback: 12 months from the paid date. Notice: 30 days. Offset against other claims: permitted. Exceptions: original claim submitted fraudulently, claim payment incorrect because provider already paid for the services, or services not delivered by provider, written agreement between provider and carrier extending recoupment-by-offset beyond the 12-month limit. Provider’s right to contest: Section requires the carrier to specify in writing the specific claim(s) subject to retroactive denial/recovery and provide a written explanation of why the claim is being retroactively adjusted; § 38.2-3407.15 does not itself detail a further dispute/appeal procedure beyond those specificity and notice requirements.

Since 2026-01-01 carrier notices and explanations for a retroactive denial must be delivered electronically by the method set in the provider contract. The 12-month / 30-day-notice rule itself is unchanged.

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Except in the case of fraud, or as provided in subsections (2) and (3)... a carrier may not... [r]equest a refund from a health care provider of a payment previously made to satisfy a claim unless it does so in writing to the provider within twenty-four months after the date that the payment was made.

Lookback: 24 months from the paid date. Offset against other claims: permitted. Exceptions: fraud (no time limit), third-party/tort liability satisfaction of the claim (no time limit; carrier must be unable to recover directly from the third party), coordination of benefits (extends deadline to 30 months instead of 24). Provider’s right to contest: Provider may contest the refund request in writing within 30 days of receipt; if the provider does not contest within 30 days, the request 'is deemed accepted and the refund must be paid.' Separately, a carrier may not require payment of a CONTESTED refund sooner than 6 months after the provider received the request.

24-month lookback (30 months for COB) applies through 2026. A mental-health/SUD carve-out of 6 months (9 COB) starts 2027-01-01; the general lookback drops to 12 months (18 COB) on 2028-01-01 (2025 c 227 s 7).

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A health plan may retroactively deny a claim only for the reasons set forth in §33-45-2(a)(7)(A)(iii) through §33-45-2(a)(7)(A)(vi) of this code for a period of one year from the date the claim was originally paid. There shall be no time limitations for retroactively denying a claim for the reasons set forth in §33-45-2(a)(7)(A)(i) and §33-45-2(a)(7)(A)(ii).

Lookback: 12 months from the paid date. Offset against other claims: permitted. Exceptions: claim submitted fraudulently (no time limit), material misrepresentation in the claim (no time limit), claim payment incorrect because provider already paid, or services not delivered by provider (subject to 1-year limit), provider not entitled to reimbursement (subject to 1-year limit), service not covered by the health benefit plan (subject to 1-year limit), insured not eligible for reimbursement (subject to 1-year limit), provider fails to become credentialed after going through the credentialing process (insurer may obtain a refund of overpayments made during the credentialing period). Provider’s right to contest: Upon receipt of notice of retroactive denial, provider has 40 days to notify the plan of intent to pay OR demand a written explanation of the denial reasons. After receiving that explanation, the provider has 30 days to either reimburse (allowing an offset against future payments) or give written notice of dispute. Disputes 'shall be resolved between the parties within 30 days of receipt of notice of dispute' (or per a process agreed in the provider contract); upon resolution, the provider pays any amount due or authorizes an offset against future payments.

The 12-month limit does not apply to fraud or material misrepresentation, and an insurer may separately recoup overpayments made during a credentialing period if the provider is never credentialed.

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No statute text could be opened for this state this cycle.

Wisconsin has no general law limiting insurer recoupment of overpayments from medical providers. A narrower rule covers only PBM audits of pharmacies (Wis. Stat. §632.865(5)-(6)); contract terms govern everything else.

An action or request for reimbursement of any overpayment of a health insurance claim to a health care provider pursuant to any health insurance contract shall be brought not more than two (2) years after the date the claim was paid... unless the claim was fraudulent.

Lookback: 24 months from the paid date. Exceptions: claim was fraudulent (no time limit). Provider’s right to contest: Not addressed in § 26-15-137 — the section is purely a statute of limitations on the insurer's action/request for reimbursement; it does not create a notice, offset, or dispute-resolution procedure.

A pure two-year limitations period on the insurer's refund action; the statute sets no notice, offset or provider-appeal procedure, so contract terms govern those.

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