(a)

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

2. (2)

   1. (A) The exception for fraud means fraud that the insurer discovered after the eighteen-month period and could not have discovered prior to the end of the eighteen-month period by the exercise of reasonable diligence.
   2. (B) It does not permit a healthcare insurer to extend the eighteen-month period under the rationale that it is still investigating a claim for fraud or any similar reason.

(b)

1. (1) A healthcare insurer that exercises recoupment under this section shall give the healthcare provider a written or electronic statement specifying the basis for the recoupment.
2. (2) The statement shall contain, at a minimum, the information required by 23 CAR § 123-104.

3. (3)

   1. (A) The statement shall also include notice of any right to internal appeal by the provider.
   2. (B) If the provider initiates an internal appeal, the healthcare insurer shall suspend its recoupment efforts for the alleged overpayment until such time as the healthcare insurer has prevailed after the provider has exhausted all available internal appeals.

(c)

1. (1) “Exercise recoupment” means the commencement of recoupment together with the provision of the statement required by subsection (b) of this section and 23 CAR § 123-104.
2. (2) Once recoupment has been exercised, a healthcare insurer may continue the recoupment to its resolution.