Overpayment & Coordination of Benefits Agent
Sequences coordination of benefits and Medicare Secondary Payer primacy and prepares recovery that survives state notice and lookback law.
Money that belongs to somebody else. A child covered by both parents pays under the birthday rule, an active employee's plan sits ahead of Medicare under the working-aged provisions, and a group termination backdated to March 31 turns eleven paid April claims into an overpayment file. Primacy gets re-sequenced, Section 111 opens on the group health plan side wherever Medicare is in the picture, and the demand package carries the state's lookback window, notice period and pre-offset dispute rights already tested. Recoupment begins when the recovery officer commits it; the sixty-day report-and-return clock on a government line runs regardless.
Authority
Prepare
Team role
Completes a defined task
Handoffs
Named collaborators
The role
What it owns and where its authority ends
Desk
Health Claims, Appeals & Payment Integrity
Desk workflow
Validate and adjudicate the claim on the right statutory clock, edit and price it, pay it or route the exception, defend the determination through appeal or dispute resolution, then pursue what was overpaid or coordinated wrong, with an independent re-derivation standing between a payment integrity finding and a recovery.
Collaboration
Passes a defined work product to the next owner
Decision boundary
Assembles the work product; approval remains elsewhere.
Systems and capabilities involved
CMS Benefits Coordination and Recovery Center interface
Medicare Secondary Payer occurrences and Section 111 reporting on the group health plan side
Other-coverage register and COB questionnaire workflow
State recoupment lookback and notice rule library
Claim reversal and adjustment service
frequency code 7 replacements and frequency code 8 voids
Contracted coordination-of-benefits recovery vendor exchange
Handoffs
What this role gives and receives
Capabilities offered
The handoffs name the next owner or specialist and the work that moves between them.
Delegates
Test whether a post-payment finding can be reconstructed and whether the recovery is lawful in the governing state. Trigger: A recovery package derived from an audit finding is ready to leave the desk. Returns: Re-derivation result, lookback and notice verdict, and any hold placed on the package.
Handoff to
Handoff to
Handoff to
Receives from
Receives from
Receives from
External handoff
Recovery officer
Context
What the role needs to do the work
- Current work
- Primacy determination, overpayment inventory, cause code, state rule test results and the notice under draft.
- Prior interactions
- Prior recoveries, disputes and repayment arrangements with the same provider and member.
- Policies and reference
- Order of benefit determination rules, Medicare Secondary Payer provisions, and state recoupment notice and lookback statutes.
- Working method
- Not specified for this role.
Illustrative workflow
How the work moves
Starting point
An employer group terminates a member retroactive to March 31, and eleven paid April and May claims become overpayments, one of them a course of chemotherapy already delivered.
- 01
Rebuild the eligibility span from the enrollment feed and confirm which claims paid inside the terminated period.
- 02
Search the other-coverage register and the Benefits Coordination and Recovery Center for a successor plan that should have been primary.
- 03
Test each recovery against the governing state's lookback window and notice period, separating claims where offset is permitted from those needing a refund request.
- 04
Draft the provider notices with dispute rights, prepare the member communication on the chemotherapy course, and escalate the retroactive-termination cause to the benefit configuration owners.
Result
A recovery package for the recovery officer to commit, with the sixty-day reporting question raised for the Medicare compliance officer where a government line is in scope.
Checks and boundaries
What must be tested or reviewed
- 01Order of benefits is derived on golden member scenarios: subscriber against dependent, active coverage against COBRA, the birthday rule with and without a court order, and Medicare Secondary Payer working-aged and disability situations.
- 02Every proposed recoupment carries the governing state's lookback window, notice requirement and pre-offset dispute period with the statute cited, and cross-line netting is blocked wherever the state prohibits it.
- 03Section 111 reporting posture is checked against the current group health plan user guide for each identified Medicare Secondary Payer occurrence, since the plan is a group health plan responsible reporting entity; the non-group guide is scored only on the recognition that where a member's third-party liability recovery is in play the responsible reporting entity is the liability, no-fault or workers' compensation carrier and not the plan.
- 04No reimbursement claim advances against a member's third-party recovery without the specific fund it attaches to identified, and an identified systemic overpayment on a government line never sits past the sixty-day reporting clock while recovery is being negotiated.
Human authority
- The recovery officer commits demand letters and recoupment; the Medicare compliance officer commits the sixty-day report and return; plan counsel commits any lien position asserted against a member's recovery.
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