505 City Parkway West | Orange, CA 92868 | www.caloptima.org
Main: 714-246-8400 | Fax: 714-246-8492 | TDD/TTY: 800-735-2929
Provider Identified Overpayment Form
This form should accompany any refund payment made to CalOptima, when an overpayment has been
identified by your business office, in order to apply the refund to the correct member account.
Provider Name:
Provider Billing
Number:
Provider Phone
Number:
Provider Address:
Member Name:
Member CIN
Number:
Date(s) of Service:
Claim Number(s):
Refund Amount:
Check Number:
Important: Reason for Refund (Check all that apply)
Not our Patient/Wrong Provider
Duplicate Payment
Wrong Procedure Code (Please attach corrected claim)
Patient has Other Health Coverage (OHC) (please attach copy of OHC Explanation of Benefits [EOB])
Patient has Medicare (please attach copy of Medicare EOB)
Other (please specify): _______________________________________________________
Please enclose a copy of this form with your refund so we can apply the refund to the correct patient account.
Please mail refund payable to:
CalOptima
Attn: Claims Recovery Department
P.O. Box 11037
Orange, CA 92856
