Form 19054 - Voluntary Refund Form
Download a blank fillable Form 19054 - Voluntary Refund Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 19054 - Voluntary Refund Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1MEDICARE
Medicare Secondary Payer Jurisdiction B DME MAC
V oluntary Refund Form
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 # or NPI #: _______________________________________ Tax ID #: _____________________________________________
Contact Person: _________________________________________ Phone #: ______________________________________________
Amount of Check $: _____________________ Check #: ______________________ Check Date: ___________________________
Refund Information
For each claim, provide the following:
Patient Name: __________________________________________ HICN: ______________________________________________
Date of Service: ________________________________________ Medicare Claim Number: _____________________________
Claim Amount Refunded $: _____________________________________________________________________________________
Primary Insurance: ______________________________________ Subscriber Name: ____________________________________
Policy #: _______________________________________________ Group #: _____________________________________________
Insurer Address: ____________________________________
City: ____________________
State: ______
Zip: ___________
Telephone #: _______________________________________
Ext: _____________________
Injury Diagnosis (if applicable): ___________________________________
Injury Date (if applicable): __________________
Attach EOB
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 # 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’s
(OIG’s) Self-Disclosure Protocol are not afforded appeal rights as stated in the signed agreement presented by the OIG.
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 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 or Fax Completed Form To
National Government Services, Inc.
NGS - 17003 DME MAC MSP
P.O. Box 809273
Chicago, IL 60680-9273
Fax: 317-841-4480
National Government Services, Inc.
Page: 1 of 1
Form
#: 19054 (
517_1013)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Orp-refund-1 - Application For Refund Of Voluntary Employee Contributions Only - State University System Optional Retirement Program (susorp)
Legal
Voluntary Disclosure Questionnaire - Wyoming Department Of Revenue, Wyoming Voluntary Disclosure Agreement, Voluntary Disclosure Sales/use Tax License Application - Wyoming Department Of Revenue
Financial
Related Categories
Parent category: Medical