Opinion
DOCKET NO. A-1834-12T3
06-05-2014
NEW JERSEY DENTAL ASSOCIATION, THOMAS J. BARRIOS, D.D.S., MANOLIS G. MANOLAKAKIS, D.M.D. d/b/a THE CENTER FOR ADVANCED ORAL AND FACIAL PAIN, AND EDWARD M. JACKSON, D.M.D., Plaintiffs-Appellants, v. HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY AND UNITED HEALTHCARE INSURANCE COMPANY, Defendants-Respondents.
Arthur Meisel argued the cause for appellants. Francis X. Manning argued the cause for respondent United Health Care Insurance Company (Stradley Ronon Stevens & Young, L.L.P., attorneys; Mr. Manning, of counsel and on the brief; Ian M. Long, on the brief). James P. Flynn argued the cause for respondent Horizon Blue Cross Blue Shield of New Jersey (Epstein Becker & Green, P.C., attorneys; Mr. Flynn, of counsel and on the brief; Amy E. Hatcher, on the brief). Christine Machnowsky, Deputy Attorney General, argued for amicus curiae the Department of Banking and Insurance (John J. Hoffman, Acting Attorney General, attorney; Melissa H. Raksa, Assistant Attorney General, of counsel; Ms. Machnowsky, on the brief).
NOT FOR PUBLICATION WITHOUT THE
APPROVAL OF THE APPELLATE DIVISION
Before Judges Yannotti and Ashrafi.
On appeal from Superior Court of New Jersey, Chancery Division, Middlesex County, Docket No. C-052-11.
Arthur Meisel argued the cause for appellants.
Francis X. Manning argued the cause for respondent United Health Care Insurance Company (Stradley Ronon Stevens & Young, L.L.P., attorneys; Mr. Manning, of counsel and on the brief; Ian M. Long, on the brief).
James P. Flynn argued the cause for respondent Horizon Blue Cross Blue Shield of New Jersey (Epstein Becker & Green, P.C., attorneys; Mr. Flynn, of counsel and on the brief; Amy E. Hatcher, on the brief).
Christine Machnowsky, Deputy Attorney General, argued for amicus curiae the Department of Banking and Insurance (John J. Hoffman, Acting Attorney General, attorney; Melissa H. Raksa, Assistant Attorney General, of counsel; Ms. Machnowsky, on the brief). PER CURIAM
This matter returns following a previous decision in which we remanded to the Chancery Division for consideration of legal arguments that were first raised on appeal. N.J. Dental Ass'n v. Horizon Blue Cross Blue Shield of N.J., No. A-6014-10 (App. Div. May 30, 2012). The primary issue is whether the payers of dental insurance benefits may recover overpayments made directly to out-of-network dentists by offsetting the overpayments against benefits that are due on the claims of wholly unrelated patients. We conclude they may. We affirm the Chancery Division's dismissal of plaintiffs' amended complaint seeking injunctive relief against such offsets.
I.
Plaintiffs are the New Jersey Dental Association (NJDA) and three named dentists, Drs. Barrios, Manolakakis, and Jackson. Defendants are Horizon Blue Cross Blue Shield of New Jersey (Horizon), which is a health service corporation that issues health insurance plans and also administers self-funded health insurance plans, and United Healthcare Insurance Company (United), which is a group health insurer. The three dentists were not within the network of either Horizon's or United's health care providers. They made claims directly to Horizon and United for treatment they provided to patients that they believed were covered by one or the other defendant. Horizon and United promptly made payments directly to the dentists on those claims, and later sought to recoup those payments as mistakenly made.
In our previous decision, we summarized the nature of the dispute and the litigation. The remand did not affect the factual record, and so, we repeat that summary:
The parties essentially dispute whether defendants are entitled to recoup overpayments that defendants mistakenly paid to the out-of-network individual dentists. The individual dentists performed dental work, properly charged the patients, and issued bills to defendants for services rendered. It is undisputed that defendants erred by overpaying the individual dentists because defendants mistakenly believed that the patients in question were eligible to receive benefits. Defendants contend that they are entitled to seek recoupment of those overpayments statutorily by withholding payment on subsequent claims made by the individual dentists, who argue that they are innocent third-parties
allowing them to retain the overpayments. . . .
The relevant facts concerning the individual dentists are as follows. Dr. Jackson provided dental services to four patients insured by United, but was not a United provider when he performed those services. He then submitted claims to United seeking payment of any insurance benefits to which the patients were entitled. United paid Dr. Jackson for his services within days of receiving the claims, but thereafter determined that the four patients were ineligible to receive benefits. United requested that Dr. Jackson reimburse it, he refused, and United then recovered the overpayment by withholding it from payments for subsequent claims made by Dr. Jackson for dental services he rendered on different patients.
Similarly, Dr. Barrios and Dr. Manolakakis provided dental services to patients insured by Horizon. Neither Dr. Barrios nor Dr. Manolakakis participated in Horizon's network of providers when they performed their dental work on those patients. Horizon paid Dr. Barrios and Dr. Manolakakis for dental services rendered, and then Horizon realized that it had overpaid the dentists. Horizon requested that Dr. Barrios and Dr. Manolakakis refund the difference. When they refused, Horizon recovered the overpayment amount, just as United did, by withholding it from payments for future claims made by Dr. Barrios and Dr. Manolakakis for dental services rendered on different patients.
Plaintiffs then filed their complaint, which sought money damages and declaratory relief. The individual dentists sought damages for the overpayments recouped by defendants. In its "representational capacity" on behalf of its members, the NJDA
sought to enjoin defendants from "seek[ing in the future] reimbursement from dentists who are innocent third party creditors."
[Id. (slip op. at 3-6).]
Overpayment does not mean that Horizon or United paid more than the doctors' claims or that the doctors overcharged for their services. Rather, the benefits paid to the doctors were mistaken payments because the patient was then not covered by the dental insurance plan that paid the claim, or for another reason under the terms of the dental plan. The mistakes were not the doctors' but may have occurred as a result of prompt, electronic processing of the doctors' claims by Horizon or United.
In our prior decision, we held that the NJDA has standing to seek injunctive relief in this case on behalf of all members of its organization situated similarly to the three named plaintiff-dentists. Id. (slip op. at 2, 7-11). We remanded to the Chancery Division to consider new arguments made by plaintiffs on appeal regarding the scope and applicability of statutory provisions in dispute that address reimbursement or recoupment of overpayments. The Chancery Division was to address whether the statutes apply to "stand-alone" or "dental only" insurance benefit plans, and also to consider whether the New Jersey Department of Banking and Insurance (DoBI) has primary jurisdiction over the dispute. Id. (slip op. at 2-3). Since all parties, as well as DoBI, take the position that primary jurisdiction rests with the courts and not DoBI, and the Chancery Division so held, we do not address that issue further.
DoBI appeared before the Chancery Division as amicus curiae and agreed with defendants that they had properly followed the statutes applicable to insured claims in offsetting overpayments against claims for unrelated patients. DoBI took no position with respect to recoupment of overpayments where Horizon was merely the administrator of a self-funded dental plan. The Chancery Division adopted DoBI's view of the relevant statutes, and added that defendants also had a common law right to recover overpayments, which authorized Horizon's recoupment on a claim for which it acted as administrator.
Plaintiffs now appeal from the Chancery Division's orders granting summary judgment to defendants and dismissing plaintiffs' amended complaint. Plaintiffs argue that the pertinent statutes that address reimbursement of overpayments and permit recoupment against the claims of other patients do not apply to stand-alone or dental-only plans, and that the common law right of restitution does not permit recovery against an innocent third party to whom a payment has been made through the mistake of the payer. We are not persuaded by plaintiffs' arguments.
II.
We first consider the applicability to stand-alone dental plans of the overpayment recovery provisions in N.J.S.A. 17:48E-10.1(d)(10), (11), and N.J.S.A. 17B:27-44.2(d)(10), (11), the first of which applies to Horizon as a health service corporation and the second to United as a group health insurer. In identical language, the two statutes provide the timing, manner, and procedural requirements by which a "payer" may seek reimbursement for an overpayment from a "health care provider." We need not quote the text of the statutes because the time limitations and procedural requirements are not in dispute here. In brief, the statutes require that the insurer first request reimbursement from the health care provider who has been overpaid. Here, defendants made requests to all three doctors, and the doctors declined to reimburse the overpaid amounts.
Relevant to the issue on appeal is the provision of subsection (11) of each statute stating that:
The payer may collect the funds for the reimbursement request by assessing them against payment of any future claims submitted by the health care provider after the 45th calendar day following the submission of the reimbursement request to the health care provider or after the health care provider's rights to appeal . . . haveThus, the quoted provisions authorize the payer entity to recoup overpayments from claims payable for a different patient.
been exhausted if the payer submits an explanation in writing to the provider in sufficient detail so that the provider can reconcile each covered person's bill.
[N.J.S.A. 17:48E-10.1(d)(11); N.J.S.A. 17B:27-44.2(d)(11) (emphasis added).]
The provisions for reimbursement and recoupment were added to the statutes by the Health Claims Authorization, Processing and Payment Act (HCAPPA). L. 2005, c. 352. Before the enactment of HCAPPA, the larger statutory framework did not contain any provisions that regulated or authorized overpayment recovery. See ibid. As we will discuss later, the right of reimbursement or recoupment derived from the common law.
The Legislature enacted the larger statutory framework in 1999 to regulate electronic submission of claims and their prompt payment. In the health care insurance field, the 1999 legislation is known as HINT/Prompt Payment Act. L. 1999, c. 154. That act contained the first iterations of the statutes at issue in this appeal. Ibid. Furthermore, it contained eight sections, identical in substance, that governed eight different types of payer entities, including health service corporations, individual and group health insurers, dental service corporations, and dental plan organizations. Ibid. The different sections of HINT applied to claims under all types of plans issued by the respective entity. See, e.g., N.J.S.A. 17B:30-27. Although HINT did not define many of its terms, terms were defined in a companion act issued at the same time. See L. 1999, c. 155; N.J.S.A. 17B:30-26.
HCAPPA amended the sections of HINT that are pertinent in this appeal. L. 2005, c. 352, §§ 12, 14. It introduced the overpayment reimbursement provisions that are in dispute. Ibid. Plaintiffs argue that the HCAPPA amendments do not include stand-alone dental insurance plans. Defendants contend that the statutory framework as a whole, and its legislative history, demonstrate a legislative intent to allow recoupment from standalone dental plans. DoBI contends the statutes are based on the payer entity, such as Horizon and United, rather than on the type of claim submitted to those entities, and so, the recoupment statutes authorize recoupment on all claims, including from stand-alone dental plans.
In interpreting statutes, courts strive to effectuate the Legislature's intent. State v. Gandhi, 201 N.J. 161, 180-81 (2010); State v. Butler, 89 N.J. 220, 226 (1982). Generally, when the language is clear and unambiguous, courts "need delve no deeper than the act's literal terms to divine the Legislature's intent." Ghandi, supra, 201 N.J. at 180 (quoting Butler, supra, 89 N.J. at 226). However, courts should not adopt an interpretation that conflicts with the statute's legislative intent, and instead should effectuate the legislative intent "as it may be gathered from the [statute] read in full light of its history, purpose, and context." Chasin v. Montclair State Univ., 159 N.J. 418, 426-27 (1999) (quoting State v. Haliski, 140 N.J. 1, 9 (1995)).
Plaintiffs argue the subsection (d)(11) recoupment provisions of the two statutes that we quoted do not apply to stand-alone dental plans because the statutes refer in a separate subsection to "the health benefits plan." N.J.S.A. 17:48E-10.1(d)(1)(c); N.J.S.A. 17B:27-44.2(d)(1)(c). "[H]ealth benefits plan" is defined as "a benefits plan which pays or provides hospital and medical expense benefits," N.J.S.A. 17B:30-26; N.J.A.C. 11:22-1.2(a), and stand-alone dental plans do not pay or provide those benefits.
Plaintiffs contend that only claims "for a service or supply covered under the health benefits plan" are covered by subsection (d) of the two statutes, and that the reimbursement and recoupment provisions of subsections (d)(11) are also limited to recovery of overpaid amounts on claims for such "health benefits plans" that provide hospital and medical expense benefits. Arguing that "the plain language" of the statutes does not include stand-alone dental plans, plaintiffs contend that the quoted provision of subsection (d)(11) must be read in conjunction with subsection (d)(1)(c) to exclude standalone dental plans from the payer's right of recoupment.
But the statutory terms are not as plain as plaintiffs contend. The language of subsection (d)(11) that we previously quoted does not itself contain a limitation to "health benefits plan." It refers to "health care provider," which is more broadly defined as inclusive of individuals and entities providing "covered service defined by the health benefits or dental plan." N.J.S.A. 17B:30-26; see also N.J.S.A. 17B:30-23 (using "health care claim," "health claim," and "health care benefits claims" as "including institutional, professional, pharmacy, and dental health claims").
Furthermore, the legislative history supports a broader interpretation of the reimbursement and recoupment provisions than plaintiffs ascribe to them. The prior version of subsection (d) applied to both health benefits plans and dental plans, and the provisions of the larger statutory framework apply based on the status of the payer entity and not the type of insurance plan on which a claim is made. Nothing in the legislative history of HCAPPA evinces a legislative intent to exclude stand-alone dental plans from the amendments to the relevant prior statutes. The language of paragraphs (d)(1)(c) and (d)(11) is at best ambiguous as to the recoupment provisions' applicability to stand-alone dental plans.
Horizon also argues that a related statutory provision, N.J.S.A. 17:48E-10.2(a)(1), demonstrates that dental benefits are covered by the overpayment framework in N.J.S.A. 17:48E-10.1(d)(10), (11). Subsection 10.2(a)(1) was enacted separately in 2003 to address claims made by out-of-network providers. L. 2003, c. 250, § 3. It states in relevant part: "a health service corporation that makes a dental benefit payment to a covered person for services rendered by an out-of-network dentist shall issue the payment to the covered person in accordance with the time frames set forth in [N.J.S.A. 17:48E-10.1]." N.J.S.A. 17:48E-10.2(a)(1). Horizon contends this cross-referencing language incorporates the time frame for the reimbursement and recoupment provisions of N.J.S.A. 17:48E-10.1(d)(11), thus showing those provisions apply to all dental plans for which Horizon is the insurer. Plaintiffs respond that subsection 10.2(a)(1) is irrelevant to the dispute in this case. At the very least, however, subsection 10.2(a)(1) reveals that the meaning of the pertinent statutes within an entire statutory framework is not so plain as plaintiffs contend.
When a statute subject to alternative interpretations has been interpreted by an agency charged with its enforcement, the agency's interpretation is entitled to substantial deference by the courts. See In re Distrib. of Liquid Assets Upon Dissolution of Union Cnty. Reg'l High Sch. Dist. No. 1, 168 N.J. 1, 10-11 (2001). Courts should adopt the same interpretation "even if that interpretation is not the only permissible one or even the most reasonable." Sherman v. Citibank (S.D.), N.A., 143 N.J. 35, 57-58 (1995). At the same time, courts are not bound by the agency's interpretation, especially when the agency adopts inconsistent positions. See id. at 57-59.
Here, DoBI is charged with administering and enforcing the relevant statutes. It has interpreted them as applying on a payer entity basis, meaning that these statutes apply to all claims submitted to an entity such as Horizon or United, regardless of the claim type. DoBI interpreted the statutes in this way in its Bulletin No. 06-16 published shortly after HCAPPA was enacted. According to this bulletin, the overpayment provisions of N.J.S.A. 17:48E-10.1 and N.J.S.A. 17B:27-44.2 "apply to all claim payments made on or after July 11, 2006." Dep't of Banking and Ins., Bulletin No. 06-16, 5 (July 10, 2006). The bulletin further asserts that "the intent of the Legislature was for the law to apply broadly across health care providers and health care services." Id. at 6.
Plaintiffs argue that DoBI's interpretation should not be credited by the court because DoBI previously issued answers to Frequently Asked Questions (FAQs) in which it excluded standalone dental plans in its interpretation of the relevant provisions of HCAPPA. Defendants and DoBI, on the other hand, argue that the 2006 bulletin more accurately stated DoBI's position.
We are persuaded by the arguments of defendants and DoBI that the reimbursement and recoupment provisions of N.J.S.A. 17:48E-10.1(d)(10), (11) and N.J.S.A. 17B:27-44.2(d)(10), (11) apply based on the identity of the payer entity rather than on the type of claim that is submitted. The payer entity is required to accept electronic claims and make prompt payment on those claims. That requirement includes payment on claims under stand-alone dental plans.
The prompt payment provisions of the 1999 legislation may result in mistakes in determination of coverage and the appropriateness of payment. Rather than delay payments while the insuring entity investigates each claim, the Legislature preferred prompt payment to the medical or dental provider. These provisions benefit all health care providers, including plaintiffs. The 2005 HCAPPA amendments also benefit health care providers in setting time limits and other procedural requirements if the insurer requests reimbursement from the provider, and if it resorts to self-help recoupment. The Legislature gave no indication, however, that it intended to revise the existing ability of the insurers to recoup overpaid amounts from dentists who make claims through stand-alone dental plans.
We conclude that the overpayment recovery provisions of N.J.S.A. 17:48E-10.1(d)(11) and N.J.S.A. 17B:27-44.2(d)(11) apply based on the type of payer entity, not the type of claim that is submitted to that payer entity. Therefore, the reimbursement and recoupment provisions apply to stand-alone or dental-only plans.
III.
Plaintiffs argue next that there was no "overpayment" to be recovered, as that term is defined by the common law. Specifically, plaintiffs contend "overpayment" should be defined "as (1) the sum in excess of the amount by which a mistaken payment reduces a valid obligation, or (2) the amount by which the recipient has been unjustly enriched." They argue that their charges were valid obligations of their patients and the payments were not in excess of the charges. They contend they have not been unjustly enriched.
As we have stated, however, one purpose of the reimbursement and recoupment provisions is to protect health care providers in requiring that the payer entity follow certain procedures in recouping overpayments and that it give a written explanation of the changes it has made to past mistaken payments. These provisions were enacted in conjunction with the electronic claims processing and prompt payment required by HINT/Prompt Payment Act. They were an accommodation to both payer entities and health care providers in regulating the manner of recoupment after mistaken payments. Mistaken payments include those made for patients who were later discovered not to be covered by the insurance plan or as to whom the dentist was mistakenly paid for other reasons. The term "overpayment" applies to the factual circumstances presented in this appeal.
Plaintiffs argue further that even if an overpayment is made, it cannot be recovered through subsection (d)(11) when the provider is an innocent third party creditor. They contend the common law recognizes a defense by an innocent third party creditor to a claim for restitution.
Horizon and United respond that, not only did N.J.S.A. 17:48E-10.1(10), (11) and N.J.S.A. 17B:27-44.2(10), (11) abrogate the common law if it is inconsistent, but New Jersey has not adopted an innocent third party exception to the common law right of restitution. Most significantly, Horizon and United argue that, even if such an exception were the law in this State, they are not seeking restitution from plaintiffs. Instead, they exercised self-help to recoup overpayments, and any defenses to an affirmative claim for restitution are inapplicable to such self-help remedies.
In New Jersey, "one who has paid money under a mistake of fact but for which payment would not have been made may have restitution from the payee notwithstanding that the mistake was unilateral and a consequence of the payor's negligence, providing, however, that such restitution will not prejudice the payee." Great Am. Ins. Co. v. Yellen, 58 N.J. Super. 240, 244 (App. Div. 1959). Some states and the Restatement Third of Restitution and Unjust Enrichment § 67 (2011) recognize an "innocent third party exception" to this rule. According to that exception, a payee who takes without notice of the mistake is provided a defense to the payer's claim for restitution.
Illustration 12 under Section 67(1) of Restatement Third of Restitution and Unjust Enrichment seems particularly pertinent. It states:
Hospital treats Patient who has medical insurance with Insurer. Hospital provides services for which its reasonable and customary charge is $200,000, takes an assignment of Patient's claim against Insurer, and submits its bill. Insurer pays Hospital $200,000 before discovering that coverage under Patient's policy is limited to $125,000. Insurer has a prima facie entitlement to restitution from Hospital in the amount of $75,000, but Hospital has an affirmative defense by the rule of this section. Hospital is not liable to Insurer if Hospital obtains payment before learning of Insurer's mistake.
New Jersey courts have not adopted this exception. One published opinion of a trial court has described the exception as "extreme" and "unsound." New Jersey Mfrs. Ins. Co. v. Gonsalves, 366 N.J. Super. 459, 479 (Law Div. 2003).
Plaintiffs nevertheless argue that our decision in H. John Homan Co. v. Wilkes-Barre Iron and Wire Works, Inc., 233 N.J. Super. 91 (App. Div. 1989), supports adopting the Restatement exception. In Homan, we held that an account debtor could not recover the payment it made by mistake if an assignee of the creditor was without notice of the mistake when it received the payment. See id. at 95-96. In doing so, we relied on the Restatement of Restitution § 14 (1937), which is the predecessor to Section 67 of the Restatement Third of Restitution and Unjust Enrichment. Homan, supra, 233 N.J. Super. at 97-98.
Regardless of whether plaintiffs are correct in their analysis of Homan, Horizon and United are not suing affirmatively for restitution. Instead, they exercised self-help to recoup overpayments from later claims. In Homan, we said that, if the payer "had not made payment in full" to the payee under the assignment, the payer "could have deducted from the amount due the sum necessary." Id. at 96. We also said that if the payee sued the payer to recover the amount due, the payer "would have been entitled to a setoff in the amount" of the overpayment. Ibid. Thus, Homan supports defendants' ability to exercise self-help in recovering overpayments by offsetting as yet unpaid claims.
Horizon and United also argue that a comment to the Restatement section 67 supports their ability to recoup the overpayments. That comment states: "A payment that is not yet final is one that may be recovered by legitimate self-help, without reference to either claims or defenses in restitution." Restatement Third of Restitution and Unjust Enrichment § 67, comment h. Here, defendants and plaintiffs are engaged in an ongoing relationship of claims submissions and payments. This relationship continually generates new claims that have not yet become final. The Restatement and the common law do not prevent a payer from withholding payments that are yet unpaid as a self-help means of recovering prior overpaid amounts.
Because the common law is not inconsistent with the ability of Horizon and United to offset future payments against amounts that were overpaid, we need not decide whether the innocent third party exception to an affirmative claim for restitution should be adopted as part of our State's common law. That exception is not contrary to a payer's right to exercise self-help in recouping an overpayment from a future claim.
In addition, if the common law were to the contrary, subsection (d)(11) of the relevant statutes would abrogate the common law and give the payer entities the right to recoup overpayments. "No statute is to be construed as altering the common law, farther than its words import." Velazquez v. Jimenez, 172 N.J. 240, 257 (2002) (quoting Oswin v. Shaw, 129 N.J. 290, 310 (1992)); accord Marshall v. Klebanov, 188 N.J. 23, 37 (2006). With respect to abrogation of the common law, statutes are to be construed narrowly, but "[i]f the language is clear, then 'the sole function of the courts is to enforce it according to its terms.'" Marshall, supra, 188 N.J. at 37 (quoting Hubbard ex. rel. Hubbard v. Reed, 168 N.J. 387, 392 (2001)).
Here, the relevant statutes provide a detailed framework governing overpayment recovery. The statutes provide insurers the ability to recoup overpayments without referencing any available defenses, while also setting forth the rights of a provider to appeal such recoupments. See N.J.S.A. 17:48E-10.1(d)(11), (e); N.J.S.A. 17B:27-44.2(d)(11), (e). Even construed narrowly, the statutes abrogate any common law defense argued by plaintiffs.
With respect to claims under self-funded or "administrative services only" plans, plaintiffs argue that the statutes only apply to insured claims. Furthermore, they cite an unpublished trial court opinion and contend that the common law prohibits recoupment of payments made pursuant to self-funded plans. As we have stated, the common law does not prohibit recoupment. Horizon's self-help recoupment of an overpayment on a claim it administered for a self-funded plan is subject to the same analysis under the common law as we have discussed with respect to insured claims.
The Chancery Division correctly dismissed plaintiffs' cause of action for injunctive relief against Horizon and United seeking to prohibit the self-help recoupment measures they employed against the three named dentists and other dentists similarly situated.
IV.
Finally, the NJDA appeals from denial of its request for injunctive relief to prohibit defendants from issuing explanation of benefits forms to their patients stating that the dentists' charges have been paid by defendants when, in fact, no payment was made on those claims from which overpayments were recouped. The NJDA argues these notifications are not truthful.
As we previously quoted, subsection (d)(11) of N.J.S.A. 17:48E-10.1 and N.J.S.A. 17B:27-44.2 requires that the payer entity "submit[] an explanation in writing to the provider in sufficient detail so that the provider can reconcile each covered person's bill." Defendants sent plaintiffs explanation of benefits forms indicating the amount being recouped, the claim it was being recouped from, and the claim it was being recouped to pay. They also sent an adjusted explanation of benefits form to the subscriber whose claim was being recouped, indicating the reason for rescinding payment and stating the patient's responsibility for payment of that bill to the doctor. The explanation of benefits form sent to a patient from whose claim the recoupment was made stated that payment was made on that patient's claim.
Defendants contend these notifications comply with the statutory requirement of providing documentation so that the health care provider can reconcile its billing records. We agree. The plaintiff-dentists are able to determine which patient's bills have been paid and which have been rescinded because of an earlier mistaken payment. Defendants sent documentation in sufficient detail so that the provider can reconcile each patient's bill. Consequently, the NJDA was not entitled to the injunctive relief it requested.
Affirmed.
I hereby certify that the foregoing is a true copy of the original on file in my office.
CLERK OF THE APPELLATE DIVISION