Carelon Is Recouping Overlapping PRP Payments. Here Is What Your Records Need to Show.

If you run a Psychiatric Rehabilitation Program in Maryland, check your next Provider Summary Voucher for a denial code you may not have seen before: PRPP. It means Carelon has reversed a PRP claim because another provider was also paid for the same participant in the same service month, and the money is coming back out of a future remittance.

This is not new policy. Carelon announced the review in April and said then that adjustments would follow. The October 2 alert is the reminder that they are continuing, and it spells out what an appeal has to contain. If your program takes transfers from other PRPs, or loses participants to them, you need to know how this works before the first PRPP line lands.

What Carelon said, and when

On April 13, 2026, Carelon told PRP providers that a review of claims and authorization activity had found two things: PRP services billed with no corresponding authorization for the participant and service month, and payments issued to more than one provider for PRP services for the same participant in the same month. It said adjustments would begin that week, with recoupments shown on the PSV.

The no-authorization finding is the easier one to understand. Carelon had already said in earlier alerts that the 2025 authorization grace period did not waive authorizations, and that claims paid without one could be reprocessed and denied retroactively. If you have monthly PRP claims from 2025 with no authorization on file, those are exposed.

The overlapping services finding is the one the October 2 alert is about. PRP is billed as a monthly service. When a participant moves from one PRP to another mid-month, or is enrolled in two at once, Carelon sees two claims for the same person and the same month. One of them is treated as a duplicate and reversed, and the reversal shows up on your PSV with EOP denial code PRPP.

What to do when you see PRPP on a voucher

First, do not assume it is correct. Carelon's own alert says providers who believe a recoupment was made in error may appeal. The reversal is automated against claim data; the appeal is where the clinical record gets looked at.

Second, do not assume it is wrong. Pull the participant's chart and confirm three dates: when they were admitted to your program, when they were discharged (if they were), and whether you know of another PRP serving them in that month. If the participant was enrolled with you for the whole month and you have no transfer in or out, the duplicate is on the other provider's side and your appeal should say so. If the participant transferred to you on the 20th and the prior program billed the full month, you may still be entitled to payment, but you will need to show the admission date and the referral or discharge from the other program.

The appeal packet

The October 2 alert lists what a Provider Claim Appeals Request Form must include:

• The check or EFT reference number and payment date shown on the PSV.
• The affected claim number or numbers, participant information, dates of service, and billed procedure codes.
• A clear explanation of why the provider disputes the recoupment.
• Any relevant care coordination, intake, discharge, or transition documentation that supports the appeal.

The fourth item is the whole case. "Services were not duplicative" is a documentary claim. What demonstrates it is the intake record showing the admission date and the referral source, the discharge or transition note from the program the participant left, and care coordination notes showing you knew about the other program and the handoff was planned. A rehabilitation plan dated in the month in question helps. A stack of daily contact notes alone does not, because the question is not whether you delivered services, it is whether another program was also entitled to bill for the same month.

Chapter 12 of the Maryland Public Behavioral Health System Provider Manual covers claim appeals, including the timeline. Chapter 17, section 17.03, covers recoupments and offsets, including how a reversal is netted against future payments.

Preventing the next one

Most overlapping-month recoupments come from transfers that were never documented as transfers. The participant walks in, says they used to go somewhere else, and nobody closes the loop. Three habits close it:

1. Ask at intake. Every PRP intake should record whether the participant is currently or was recently enrolled in another PRP, and the name of the program. If the answer is yes, get the discharge date before you bill the first month.
2. Document the handoff. A one-line care coordination note ("spoke with X program on October 6, participant discharged there effective October 3, records requested") is the difference between an appeal that wins and one that does not.
3. Discharge on time. If a participant leaves your program, close the enrollment with a discharge date in the month they left. A program that keeps billing a participant who has moved on is the other half of every PRPP reversal.

The same logic applies to child and adolescent PRP

Carelon's September 21 alert on PRP-M (child and adolescent) is about a different rule with the same effect. PRP-M may not be routinely provided alongside mobile treatment or ACT, Targeted Case Management Level II or III (and never alongside Level I), mental health IOP or PHP, respite, or SUD IOP or PHP. Limited exceptions exist for youth with repeated ED use for mental health, youth stepping down from an RTC, youth with a history of repeated psychiatric hospitalization, or youth at risk of RTC or out-of-home placement, and those exceptions are meant to be short term.

The practical point is the same as for overlapping PRP months: if another level of care is active for the participant, your PRP-M month is exposed, and the exception has to be documented in the chart before the claim goes out, not reconstructed after a recoupment.