Voluntary Overpayment Return

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VOLUNTARY OVERPAYMENT RETURN
An Independent Licensee of the Blue Cross and Blue Shield Association.
Please check only one and refer to the mailing addresses at the bottom of this form. This refund concerns claim(s) for:
K
K
K
K
Blue Cross and Blue Shield
NASCO
Medicare A
Medicare B
REFUND INFORMATION
Provider / NPI Number
Tax ID Number
Provider Name
Person to contact (if necessary) within above named provider’s office
Extension
Telephone Number
(
)
Patient Account Number
Patient Name (one patient per form, please)
Patient Contract Number
CLAIM NUMBER
REMIT DATE
AMOUNT
DATE OF SERVICE
K
Date
Approved by
$
TOTAL AMOUNT:
DEDUCT
K
(check one)
ENCLOSED
REASON FOR REFUND ADJUSTMENT
K
DUPLICATE PAYMENT — ORIGINAL CLAIM NUMBER ______
________________________________________
K
K
NOT OUR PATIENT
INCORRECT PROVIDER
K
K
CORRECTED BILLING
CHARGES/CLAIMS SUBMITTED IN ERROR
K
MEDICARE PRIMARY — MEDICARE NUMBER
______________________________________________________
K
OTHER INSURANCE PRIMARY — OTHER INSURANCE INFORMATION
__________________________________________ __
K
WORKER’S COMPENSATION
K
AUTO INSURANCE — COMPANY _____________________________________ INSURED __________________________
K
OTHER (please explain)
____________________________________________________________________________________
______________________________________________________________________________________________________________
MAILING ADDRESS
IF returning to Blue Cross and Blue Shield of Alabama or NASCO, mail to:
IF returning to Medicare Part A or Medicare Part B, mail to:
Blue Cross and Blue Shield of Alabama
MEDICARE
ATTENTION: PAYMENT PROCESSING
— OR —
300 Corporate Parkway
PO Box 360899
Birmingham, AL 35242-5425
Birmingham, AL 35236-0899
ACT-110 (Rev. 7-2007)

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