Fillable Medicare Je Part B Non-Msp Voluntary Checks Form (Check-Enclosed) printable pdf download

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:

NO. CAL

SO. CAL

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

Medicare

Date of

Dollar Amount to

Procedure Code to

Reason

Beneficiary Name

Number (ICN)

Number (HIC)

Service

be refunded

Code

Total

0.00

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.

REASON CODE FOR CLAIM ADJUSTMENT

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)

3B. DOWNCODE, Change CPT

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

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

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