My health plan already paid, and now the money is being taken back. What are my rights?

A take-back comes in three shapes. The plan takes money back from the clinic, and the clinic then bills you. The plan reverses a claim of yours that it had paid. Or the plan asks you for the money. The first shape has a Texas clock on the plan, not on you. Under a preferred provider plan, an insurer may recover an overpayment from a physician or provider only on two conditions. It must give written notice of the overpayment, with the basis and the specific reasons, no later than the 180th day after the provider received the payment. And the provider must not arrange repayment within 45 days of that notice [1].

If the provider disagrees, the insurer must give it an appeal. It may not recover the money until all appeal rights are used up [1]. An HMO works under the same two rules [2]. So ask the clinic for a copy of the recoupment notice, for its date, and for whether the clinic appealed.

When the plan reverses a claim of your own, your appeal rights run on the plan's notice. A group health plan's claims procedure must give you at least 180 days after you receive notice of an adverse benefit determination to appeal [3]. The plan must also give you, free of charge and on request, access to and copies of all documents, records and other information relevant to your claim [4]. Under the federal health plan rules, an adverse benefit determination also covers any rescission of coverage — a cancellation that works backwards — whether or not a particular benefit is hit at that time [5]. If your state's outside review process applies, it must allow at least four months after you receive the notice to ask for an external review [6].

So put three things in writing. Ask the plan for the provision the take-back rests on. Ask for the date of the notice. Ask for the claim file. Then count your own window from the day you received the notice, not from the date on the letter [3]. One thing the sources here do not give: whether you personally owe the clinic after a take-back. That sits in the contract between the clinic and the plan, so we do not answer it. Ask both of them, in writing.

Read Tex. Ins. Code §1301.132 and §843.350 at the links quoted here for the clock on the plan, then read 29 CFR 2560.503-1(h)(2)(iii) and (h)(3)(i) and 45 CFR 147.136 for your own appeal rights. Your plan's summary plan description names where to send the appeal and the dates it runs on.