Standard Operating Procedure
OPS-SOP-004 — Dispute & Recoupment
1. Purpose
This SOP defines the process for identifying, logging, tracking, and resolving disputes related to claim overpayments, invoice discrepancies, billing errors, or eligibility issues across each participating employer plan under the Unity Care Member Plan Master Trust. It also covers recoupment of funds where applicable.
🔴 Critical Note — Dispute Log Does Not Currently Exist
As of this writing, no formal dispute log or tracking system exists. This SOP establishes the procedure; the tracking tool must be built before this process can be executed. See Open Items section.
2. Scope
Applies to all disputes arising from QC processes (SUB-001, SUB-002), invoice validation (OPS-SOP-002, OPS-SOP-003), GL reconciliation, or vendor billing errors across Allied TPA, ProAct PBM, and other plan vendors.
3. Roles & Responsibilities
| Role | Responsibility |
|---|
| Operations | Primary dispute owner. Log case, notify vendor, track resolution, close case. |
| Finance | Record receivables, credits, and GL adjustments upon resolution. Validate refund or credit amounts. |
| Legal | Advise and escalate for material or unresolved disputes. Determine if formal demand is required. |
| Compliance | Ensure all dispute documentation is retained per ERISA. Review for plan-level compliance implications. |
| Vendor (Allied, ProAct, other) | Respond to dispute notification. Issue credit or refund if agreed. Provide corrected documentation. |
4. Procedure
Subprocess reference: SUB-007 (Dispute & Recoupment flow)
1. Identify Dispute: Disputes may be identified from:
- Eligibility QC exceptions (SUB-001)
- Funding QC anomalies (SUB-002)
- Invoice validation failures (OPS-SOP-002, OPS-SOP-003)
- GL reconciliation discrepancies
- Vendor notification of billing error
2. Log Dispute Case: Operations creates a dispute case in the Dispute Log [TBD] with:
- Case ID (auto-generated or sequential)
- Date identified
- Source (which process identified it)
- Vendor involved
- Disputed amount (if monetary)
- Description of issue (no PHI)
- Assigned owner
- Status: Open
3. Notify Vendor: Operations sends written notification to the vendor requesting formal review of the dispute. Notification is logged in the Dispute Log with date/time sent.
4. Vendor Review Period: Vendor has [TBD] business days to respond. Operations follows up if no response within [TBD] business days.
5a — Vendor Agrees: If vendor agrees with the dispute:
- Vendor issues credit or refund per agreed terms
- Finance records the receivable or credit and adjusts the expense in GL
- Operations updates Dispute Log: status = Resolved, resolution type = Credit/Refund, date closed
- All documentation retained per Evidence Retention table
5b — Vendor Does Not Agree: If vendor disputes or does not respond:
- Operations documents vendor's position and rationale in Dispute Log
- Escalate to Legal to advise on next steps (formal demand, contract remedy, or close)
- Legal determines whether formal demand letter is warranted
- Operations updates Dispute Log with Legal disposition and date
- Case closed with status = Closed — Unresolved or Escalated
6. Close Case: Operations closes the dispute case in the Dispute Log with:
- Resolution type
- Date closed
- Reference to evidence retention location
5. Controls
| Control | Description | Owner | Frequency |
|---|
| Dispute Logging | Every dispute logged in Dispute Log immediately upon identification | Operations | Per event |
| Vendor Notification | Written notice sent and timestamped for all disputes | Operations | Per event |
| Follow-Up SLA | Operations follows up within [TBD] days if no vendor response | Operations | Per event |
| Legal Escalation Threshold | All unresolved or material disputes escalated to Legal within [TBD] days | Operations | Per event |
| GL Adjustment Authorization | Finance must validate and record all credits/refunds in GL | Finance | Per resolution |
| Evidence Retention | All dispute records retained 6 years per ERISA | Operations, Compliance | Per event |
6. Evidence Retention
| Document | Location | Retention Period |
|---|
| Dispute log entry | Dispute log [TBD] | 6 years (ERISA) |
| Vendor notification (written) | Ops records [TBD] | 6 years (ERISA) |
| Vendor response or non-response record | Ops records [TBD] | 6 years (ERISA) |
| Credit or refund documentation | Finance records [TBD] | 6 years (ERISA) |
| GL adjustment record | Finance records [TBD] | 6 years (ERISA) |
| Legal escalation record (if applicable) | Legal records [TBD] | 6 years (ERISA) |
7. Escalation
| Trigger | Action | Escalation Owner |
|---|
| No vendor response within [TBD] days | Operations follows up formally; escalates to Legal if still no response after [TBD] days | Operations |
| Disputed amount exceeds [TBD] | Immediate Legal notification; Finance alerted for reserve implications | Operations |
| Vendor refuses credit or refund | Escalate to Legal for contract remedy review | Operations |
| Dispute has plan-compliance implications | Notify Compliance for broader review | Operations |
⚠️ Open Items — Tracking Tools To Be Built
- Dispute Log: PRIMARY PRIORITY — does not exist. Needs sequential case IDs, status tracking, vendor field, amount, resolution type, date opened/closed, no PHI. Suggested: shared spreadsheet or Asana project as interim; database long-term. Referenced by OPS-SOP-001, 011, 012, 013.
- Vendor Contact Directory: Standard dispute contacts at Allied and ProAct (role-based, not personal names) [TBD format]
- Dispute Escalation Thresholds: Dollar thresholds that trigger Legal and Finance notification — needs Finance/Legal sign-off [TBD]
- Legal Escalation Protocol: Documented workflow for when and how Legal is engaged [TBD]
- Evidence Retention Index: Cross-reference of dispute records to retention locations [TBD format]
OPS-SOP-004 | Unity Care Solutions, LLC — Internal / Confidential
⚑ Flag an Issue