Fillable RETURN OF MONIES VOLUNTARY REFUND FORM (Medicare & Medicaid)

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RETURN OF MONIES VOLUNTARY REFUND FORM (Medicare & Medicaid)

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RETURN OF MONIES VOLUNTARY REFUND FORM
This form should be completed fully and accompany each unsolicited/voluntary refund check
so that your refund can be properly recorded and applied.
Provider or Other Entity Name
Address State:
Provider Number NPI #
Contact Person Tax ID #
Contact Person Phone #
Amount Returned Check #
Required Information If Multiple Claims indicate “YES” and include listing
*Patient Name *Medicare ID #
*Claim Number Claim Amount Refunded
Date of Service From Date of Service To
Reason Code for Claim Adjustment Claim Billed Amount
Additional Info. eld
OIG Reporting Requirements
Do you have a corporate integrity agreement with OIG?
Are you a participant in the OIG self-disclosure protocol?
Note: Providers and other entities who are submitting a refund under the OIG’s Self-Disclosure Protocol are not afforded appeal rights as
stated in the signed agreement presented by the OIG.
MSP Information
Other Insurer Information Employer Information
Insurance Co. Name Employer Name
Subscriber Name Employer Address Line 1
Insurer Address Line 1 Employer Address Line 2
Insurer Address Line 2 City State Zip
City State Zip Policy #
Telephone Number Telephone Number
55201FC
Instructions
• For each claim the required elds to be completed on the form are noted with *. If the required elds for specic Patient/MBI &
Claim Numbers are not completed, NO appeal rights can be provided for this voluntary refund.
• Multiple Claims being refunded: If refunding multiple claims, list all claim numbers and the required data on separate forms if
necessary.
• Medicare Secondary Payment (MSP) Refunds: Include a copy of the primary insurer’s explanation of benet (EOB) &
indicate the MSP reason (see Reason Code List Below)
• Statistical Sampling: If specic Beneciary/MBI/Claims data is not available, indicate the methodology and formula used to
determine the refund amount and explain the reason for the refund
Make check payable to Medicare Part A or Medicare Part B. Mail To First Coast Service Options CASHIER at Address listed below according
to state services rendered:
PO Box City State ZIP
PO Box 3162 Mechanicsburg, PA 17055-1837
PO Box 3092 Mechanicsburg, PA 17055-1810
State - LOB
FL, PR, VI - A
FL - B
PR & VI
– B
PO Box 3121 Mechanicsburg, PA 17055-1831
Reason Codes for each Claim Incorrect Payment (Required to Select One Reason code per refunded claim on Form):
Billing/Clerical/Non-MSP
01 - Corrected Date of Service Date Required
02 - Duplicate
03 - Corrected CPT Code Correct CPT Code Required
04 - Not Our Patient
05- Mod. Add/Remove
06- Billed in Error
MSP/Other Payer Involvement
07- MSP Group Health Plan Insurance
08- MSP No Fault Insurance Date of Incident Required
09- MSP Liability Insurance Date of Incident Required
10- MSP, Workers Comp (including Black Lung) Date of Incident Required
Miscellaneous
11- Veterans Administration
12- Insufcient Data
13- Patient Enroll HMO
14- Svcs Not Rendered
15- Medical Necessity
16- Hospice
17-Other-Please Specify: Description Required
55201FC
Provider or Other Entity Name – Provider/Physician/Supplier/Entity Name
Address - Provider/Physician/Supplier/Entity Address State – State services rendered in
Provider Number – Provider Transaction Access Number
NPI # - National Provider Identier Number (10 digits)
Tax ID # - Provider Tax Identication Number
Contact Person – Name of person to contact if additional information is required
Contact’s Phone # - Phone number of contact person if additional information is required
Amount Returned – Total amount of voluntary refund check
Check # - Check number of voluntary refund check
Required Information – If returning Multiple Claims, indicate “YES” in box provided. Include listing of claims with Required Information with
check.
Patient Name – Name of patient on claim for which money is being voluntarily returned (Required for Appeal rights)
Medicare ID # - Medicare Beneciary Identication # on claim for which money is being voluntarily returned (Required for Appeal rights).
Claim Number – Claim Number for which money is being voluntarily returned (Required for Appeal rights)
Claim Amount Refunded – Amount voluntarily returned for specic claim listed
Date of Service From – Date services started for specic claim listed
Date of Service To – Date services ended for specic claim listed
Reason Code for Claim Adjustment – Select appropriate reason code listed under “Reason Codes for each Claim Incorrect Payment”
Claim Billed Amount – Original Billed amount for specic claim listed
Additional Info. Field – To be populated when Reason Codes 01, 03, 08, 09, 10 or 17 are selected.
OIG Reporting Requirements – Select Yes or No to each question.
MSP Information Other Insurer Information (Required if Reason Codes 08, 09 or 10 selected)
Insurance Co. Name – Name of Insurance Company that should have paid as primary.
Subscriber Name – Name of Subscriber to insurance that should have paid as primary.
Insurer Address – Address of Insurance Company that should have paid as primary
City/State/ZIP – City/State/ZIP of Insurance Company that should have paid as primary
Telephone Number – Telephone Number of Insurance Company that should have paid as primary
Employer Information (If Primary Insurance is Provided by Employer)
Employer Name - Name of employer that provided Primary Insurance
Employer Address - Address of employer that provided Primary Insurance
City/State/ZIP – City/State/ZIP of employer that provided Primary Insurance
Policy # - Policy # of Primary Insurance
Telephone Number - Telephone of employer that provided Primary Insurance
55201FC
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RETURN OF MONIES VOLUNTARY REFUND FORM (Medicare & Medicaid)

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Completed 10 January 2021

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