Fillable Part B Overpayment Recovery Unit Voluntary Refund Form

MEDICARE

A CMS Medicare Administrative Contractor

Part B Overpayment Recovery Unit Voluntary Refund Form

To Be Completed By Medicare Contractor

Date: __________________________________ Contractor Deposit Control #: ______________________________

Date of Deposit: ________________________ Contractor Contact Name: __________________________________

Phone #: _______________________________ Contractor Fax: ____________________________________________

Contractor Address: _________________________________________________________________________________

To 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.

Physician/Supplier or Other Entity Name: ________________________________________________________________________

Address: _______________________________________________________________________________________________________

PTAN #: ____________________________ NPI #: _______________________________ Tax ID #: ____________________________

Contact Person: _________________________________________ Phone #: _______________________________________________

Amount of Check $: _____________________ Check #: _______________________ Check Date: ____________________________

Refund Information

For each claim, provide the following:

Patient Name: ___________________________________________ Health Insurance Claim # (HIC#): ________________________

Date of Service: _________________________________________ Medicare Claim Number: _______________________________

Claim Amount Refunded $: ______________________________________________________________________________________

Reason Code for Claim Adjustment: __________(Reason codes are listed 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 number 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 Office of the Inspector

General (OIG) 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

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

Yes

Reason Codes

Billing/Clerical:

MSP/Other Payer Involvement:

Miscellaneous:

01 Corrected date of service

07 MSP group health plan insurance

12 Insufficient documentation

02 Duplicate

08 MSP no-fault insurance

13 Patient enrolled in HMO

03 Corrected CPT code

09 MSP liability insurance

14 Services not rendered

04 Not our patient(s)

10 MSP, Workers’ Comp. (including Black Lung)

15 Medical necessity

05 Modifier add/remove

11 Veterans Administration

16 Other (be specific):

06 Billed in error

_______________________________

Mail Completed Form to:

Jurisdiction 6 (IL, MN, WI)

National Government Services, Inc.

P.O. Box 809194

Chicago, IL 60680-9194

National Government Services, Inc.

648_0914

Part B Overpayment Recovery Unit Voluntary Refund Form - 2014

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