Overpayment Refund Form printable pdf download

Overpayment Refund Form

(Exhibit 1 Medicare Financial Management Manual Chapter 5, Section 411.1)

Date: ________________________________

Contractor Deposit Control # _____________Date of Deposit: _____________

Contractor Contact Name: ________________________ Phone #: _____________

Contractor Address: _________________________________________________

Contractor Fax: _____________________________________________________

______________________________________________________________________________________

SHALL BE COMPLETED BY PROVIDER/PHYSICIAN/SUPPLIER, OR OTHER ENTITY

Please complete and forward to your Medicare contractor. This form, or a similar document containing the

following information, should accompany every unsolicited/voluntary refund so that receipt of check is

properly recorded and applied.

PROVIDER/PHYSICIAN/SUPPLIER OR OTHER ENTITY NAME: ________________________________

ADDRESS: _____________________________________________________________

PROVIDER/PHYSICIAN/SUPPLIER #: _______________ TAX ID #: ______________

CONTACT PERSON: ______________________ PHONE #: _____________________

AMOUNT OF CHECK $: ___________ CHECK #: ___________ CHECK DATE: ______

REFUND INFORMATION

For each claim, provide the following:

Patient Name: ____________________________ HIC #: _____________________

Medicare Claim Number: ___________________ Claim Amount Refunded $: _________

Reason Code for Claim Adjustment: _______ (Select reason code from list below. Use one reason per

claim.)

(Please list all claim numbers involved. Attach separate sheet, if necessary)

Note: If Specific Patient/HIC/Claim #/Claim Amount data not available for all claims due to Statistical

Sampling, please indicate methodology and formula used to determine amount and reason for

overpayment: ________________________________________

NOTE: If specific patient/HIC/Claim # information is not provided, no appeal rights can be afforded with

respect to this refund. Providers/physicians/suppliers, and other entities who are submitting a refund under

the OIG’s Self-Disclosure Protocol are not afforded appeal rights as stated in the signed agreement

presented by the OIG.

For Institutional Facilities Only:

Cost Report Year (s) ________________________

(If multiple cost report years are involved, provide a breakdown by amount and corresponding cost report

year.)

For OIG Reporting Requirements:

Do you have a Corporate Integrity Agreement with OIG? ___ Yes ___ No

Are you a participant in the OIG Self-Disclosure Protocol? ___ Yes ___No

______________________________________________________________________________________

Reason Codes:

Billing/Clerical:

MSP/Other Payer Involvement:

Miscellaneous:

01 – Corrected Date of Service

07 – MSP Group Health Plan Insurance

12 – Insufficient Doc

02 – Duplicate

08 – MSP No Fault Insurance

13 – Patient Enroll HMO

03 – Corrected CPT Code

09 – MSP Liability Insurance

14 – Svcs Not Rendered

04 – Not Our Patient(s)

10 – MSP, Workers Comp.

15 – Medical Necessity

05 – Mod. Add/Remove

(Incl Black Lung)

16 – Other-Please Specify

06 – Billed in Error

11 – Veterans Administration

Updated 1/3/06

Overpayment Refund Form

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