Medicare Je Part B Non-Msp Voluntary Checks Form (Check-Enclosed)

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Non-MSP Voluntary Checks Form
Medicare JE Part B Non-MSP Voluntary Checks Form (Check-Enclosed)
Note: Do not use this form for MSP refunds.
Please check the box next to the state code where services were rendered:
Provider/Physician or other entity:
This form should accompany every unsolicited/voluntary refund check. Complete and mail this form along with a check to the
address listed on the bottom of this form. If this request is due to a clerical error or omission and wish to correct it without having
to request a formal appeal, please call the Phone Reopening department at 855-609-9960 or by submitting a reopening form.
Please do not include MSP or Demanded refunds with your non-MSP Voluntary check.
Please include the following check information: Make your check payable to Medicare Part B.
Check Number: ____________________________ Check Date: _______________________________
Reason for Refund (For OIG Reporting Requirements)
Corporate Integrity Program
OIG Self Disclosure Protocol
Voluntary Refund
Required Information: Please provide the following refund information for each claim.
Internal Control
Date of
Dollar Amount to
Procedure Code to
Beneficiary Name
Number (ICN)
Number (HIC)
be refunded
be refunded
For additional claims please use the spreadsheet located at
If denying or changing CPT codes, indicate the change needed below under 3A through 3B
If the number of claims doesn’t fit please include a spreadsheet.
1 Billed in error
4 Corrected date of service
10 Veterans Administration (VA) paid
2 Duplicate
5 Not Our Patient(s)
11 Medical Necessity
3 CPT Code change
6 Services not rendered
12 Patient in Skilled Nursing Facility
3A. Deny CPT code in full,
7 Modifier Add/Remove
13 PacMed or USFHP (US Family
provider to resubmit new code
8 Insufficient Documentation
Health Plan)
9 Patient in HMO
from ________ to ________,
Recoup the difference
14 Other: Use the following space for any additional information on the adjustment of this claim(s):
Provider Information:
Provider/Physician or other entity name: ________________________________________________________________________________
Address: ______________________________________________ City: __________________________ State: ________ Zip: ____________
Provider/Physician and/or NPI Number: _________________________________________________ Tax ID#: _______________________
Contact Person: _______________________________________________________________________________________________________
Telephone Number: ________________________ Ext.: _____________ Fax Number: _________________________ Ext: _____________
Note: If specific patient/HIC/claim Number information is not provided, no appeal rights can be afforded with respect to this
refund. Providers/physicians and other entities that are submitting a refund under an OIG Self-Disclosure Protocol are not
afforded appeal rights as stated in the signed agreement presented by the OIG.
Please send this form along with a check to: Noridian Medicare JE Part B Refunds - (XX)
(XX represents the state code where services were rendered)
PO Box 511381
Los Angeles, CA 90051-7914
Provider Contact Center (PCC) 1-855-609-9960
29317563 (3891) 6-15
A CMS Medicare Administrative Contractor
Noridian Healthcare Solutions, LLC


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