Novitas Form 8322 PDF Details

The Novitas Form 8322 is a crucial document for healthcare providers, enabling them to return funds to Medicare accurately. This procedure is essential when providers identify payments received in error or when adjustments to previously filed claims are necessary. The form is designed to be comprehensive, allowing for the recording and appropriate application of unsolicited or voluntary refunds to Medicare. It ensures that each reimbursement is accurately matched to the specific claim it addresses by requiring detailed information for each refunded claim, including provider identifiers, beneficiary details, and claim data. Providers can use the form to list multiple claims, include Medicare Secondary Payment (MSP) refunds with necessary supporting documents, and specify the reasons for the refunds using designated codes. Noteworthy, for those under OIG scrutiny or adhering to a Corporate Integrity Agreement, the form also addresses specific protocols for submitting refunds without conceding appeal rights. The Novitas Solutions addresses vary by the state in which the services were rendered, highlighting the tailored approach to processing refunds efficiently and securely. This form represents a significant aspect of maintaining compliance and transparency in healthcare billing practices, ensuring that Medicare funds are utilized correctly and responsibly.

QuestionAnswer
Form NameNovitas Form 8322
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesinsurer, MSP, TX, NM

Form Preview Example

NOVITAS SOLUTIONS - Part B

RETURN OF MONIES TO MEDICARE

Date form is being completed:

MAIL TO: Novitas Solutions - CASHIER. Please select the address according to the state you rendered services:

AR - PO Box 3091, Mechanicsburg, PA 17055-1809

CO/NM/OK - PO Box 3105, Mechanicsburg, PA 17055-1821

DCMA/DE - PO Box 3405,

Mechanicsburg, PA 17055-1848

LA - PO Box 3090, Mechanicsburg, PA 17055-1808

MD - PO Box 3404, Mechanicsburg, PA 17055-1847

MS - PO Box 3128, Mechanicsburg, PA 17055-1833

NJ - PO Box 3034, Mechanicsburg, PA 17055-1805

PA - PO Box 3304, Mechanicsburg, PA

17055-1838

TX - PO Box 3106, Mechanicsburg, PA 17055-1822

 

 

 

Please select one provider:

AR

CO

DCMA

DE

LA

MD

MS

NJ

NM

OK

PA

TX

This form, or a similar document containing the following information , should be completed fully and accompany each unsolicited/voluntary refund check so that your refund can be properly recorded and applied. In addition:

-Multiple Claims being refunded: If refunding multiple claims, list all claim numbers and the required data on a separate sheet if necessary.

-Medicare Secondary Payment (MSP) Refunds: Include a copy of the primary insurer's explanation of benefit (EOB) & indicate the

MSP reason (see below).

-Statistical Sampling: If specific Beneficiary/HIC/Claims data is not available, indicate the methodology and formula used to determine the refund amount and explain the reason for the refund.

-OIG Self Disclosure: Providers/Physicians/Suppliers and other entities submitting a refund under the OIG's Self Disclosure Protocols are not provided appeals rights as stated in the signed agreement presented by the OIG.

- OIG Reporting Requirements:

Do you have a Corporate Integrity Agreement (CIA) with the OIG?

Yes

No

 

Are you participating in the OIG Self-Disclosure Protocol?

Yes

No

For each claim the required fields to be completed are noted with *. If the required fields for specific Patient/HIC & Claim Numbers are not completed, NO appeal rights can be provided for this voluntary refund.

BILLING PROVIDER / PHYSICIAN / SUPPLIER NUMBER

*BENEFICIARY MEDICARE HEALTH INSURANCE NUMBER / HIC

 

 

 

 

NPI NUMBER

*BENEFICIARY NAME (Patient)

 

 

 

 

PROVIDER / PHYSICIAN / SUPPLIER NAME

BENEFICIARY ADDRESS

 

 

 

 

PROVIDER / PHYSICIAN / SUPPLIER ADDRESS (Street, City, State, Zip Code)

PROVIDER / PHYSICIAN / SUPPLIER REFUND CHECK NUMBER

 

 

 

 

PROVIDER OFFICE CONTACT TELEPHONE NUMBER

PROVIDER / PHYSICIAN / SUPPLIER REFUND CHECK DATE

 

 

 

 

BILLING OFFICE CONTACT NAME & TELEPHONE NUMBER

PROVIDER / PHYSICIAN / SUPPLIER TAX ID NUMBER

 

 

 

 

*CLAIM NUMBER/ICN

CLAIM BILLED

AMOUNT

DATES OF SERVICE(s)

CLAIM AMOUNT BEING RETURNED (check amount)

*REASON CODES FOR EACH CLAIM INCORRECT PAYMENT (Required to check one reason code per refunded claim):

*Billing/Clerical

*MSP/Other Payer Involvement

*Miscellaneous

01-Corrected Date of Service

02-Duplicate - Indicate

BothClaim Number/ICN's

03-Corrected CPT Code

04-Not Our Patient

05-Mod. Add/Remove

07-MSP Group Health Plan Insurance

08-MSP No Fault Insurance, Date of Incident:

09-MSP Liability Insurance, Date of Incident:

10-MSP, Workers Comp, Date of Incident:

11-Veterans Administration

12-Insufficient Doc

13-Patient Enroll HMO

14-Svcs Not Rendered

15-Medical Necessity

16-Other-Please Specify:

06-Billed in Error

 

EMPLOYER INFORMATION (MSP):

 

 

 

 

 

 

 

OTHER INSURER INFORMATION (MSP):

Name:

 

 

Name:

 

 

 

 

Address:

Address:

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip:

City/State/Zip:

 

 

 

 

 

 

Telephone # (if available):

 

 

Telephone # (if available):

Subscriber/Member/Policy #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please return this completed form with your remittance.

MEDICARE PART B

8322 (R8-13)

Mechanicsburg, PA 17050 • www.novitas-solutions.com

How to Edit Novitas Form 8322 Online for Free

10-MSP can be completed online without difficulty. Simply make use of FormsPal PDF tool to complete the job in a timely fashion. In order to make our editor better and more convenient to work with, we constantly work on new features, taking into consideration feedback coming from our users. Should you be looking to get started, here is what it requires:

Step 1: First, access the editor by clicking the "Get Form Button" at the top of this site.

Step 2: With our advanced PDF editor, you are able to accomplish more than merely fill in blank form fields. Edit away and make your docs look perfect with customized text incorporated, or optimize the original input to excellence - all that accompanied by the capability to insert your personal images and sign the file off.

This document will need specific details to be filled out, so make sure you take some time to provide what's requested:

1. First of all, once completing the 10-MSP, begin with the area that features the next blank fields:

NM writing process clarified (part 1)

2. When this array of fields is finished, you should add the needed details in PROVIDER PHYSICIAN SUPPLIER NAME, BENEFICIARY ADDRESS, PROVIDER PHYSICIAN SUPPLIER, PROVIDER PHYSICIAN SUPPLIER, PROVIDER OFFICE CONTACT TELEPHONE, PROVIDER PHYSICIAN SUPPLIER, BILLING OFFICE CONTACT NAME, PROVIDER PHYSICIAN SUPPLIER TAX, CLAIM NUMBERICN, CLAIM BILLED, AMOUNT, DATES OF SERVICEs, CLAIM AMOUNT BEING RETURNED check, REASON CODES FOR EACH CLAIM, and MSPOther Payer Involvement in order to move forward further.

Part number 2 in completing NM

Always be very mindful when filling out MSPOther Payer Involvement and PROVIDER PHYSICIAN SUPPLIER, as this is the part where most people make errors.

3. The following part should also be rather simple, Address, CityStateZip, Telephone if available, CityStateZip, Telephone if available, SubscriberMemberPolicy, Mechanicsburg PA l, Medicare Part B, and Please return this completed form - these form fields will have to be filled out here.

NM conclusion process outlined (portion 3)

Step 3: When you have looked again at the information in the file's blanks, just click "Done" to conclude your document generation. Find the 10-MSP the instant you register at FormsPal for a free trial. Conveniently gain access to the pdf file within your FormsPal account, along with any edits and changes being conveniently synced! At FormsPal.com, we strive to make sure that all your information is stored private.

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