Novitas Form 8322 – Fill Out and Use This PDF

Novitas Form 8322 is a key document for healthcare providers. It outlines the necessities for getting reimbursed by Novitas Solutions, Inc. This reimbursement process enables us to deliver healthcare services in a cost effective and efficient manner. Providers need to keep abreast of the latest Administrative Simplification Standards which require them to utilize this form in order to obtain reimbursements. We understand there may be challenges in completing the form correctly, and are here to help your organization navigate through any difficulties arising from that process. The inputs provided in this form assists us in accurately tracking and expediting payments efficiently as we rigorously abide by traditional rules and regulations governing health care reimbursement processes.

Novitas Form 8322 PDF Details

If you are an employer, submitting your Novitas Form 8322 is a requirement for new employees. When filing Form 8322 with Novitas Solutions, the information supplied will be used to determine if the employee is eligible and qualified to receive Medicare benefits. This blog post aims to provide employers with crucial information regarding when and how they should submit Form 8322 so that their new employee can qualify for Medicare coverage without difficulty or delays.

Question	Answer
Form Name	Novitas Form 8322
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	insurer, 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:

DCMA

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):
06-Billed in Error
OTHER INSURER INFORMATION (MSP):	Name:
Name:	Address:
Address:
Address:	City/State/Zip:
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:

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.

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.

Novitas Form 8322 – Fill Out and Use This PDF

Novitas Form 8322 PDF Details

Form Preview Example

How to Edit Novitas Form 8322 Online for Free

Novitas Form 8322 isn’t the one you’re looking for?

Related Documents