Novitas Form 8322 at a glance
What it is: The Return of Monies Voluntary Refund Form should be completed fully and accompany each unsolicited/voluntary refund check so that your refund can be properly recorded and applied.
Where and when to file: Statistical Sampling: If specific Beneficiary/MBI/Claims data is not available, indicate the methodology and formula used to determine the refund amount and explain the reason for the refund. Mail To Novitas Solutions CASHIER at Address listed according to state services rendered: AR - B PO Box 3091 Mechanicsburg, PA 17055-1809; LA -B PO Box 3090 Mechanicsburg, PA 17055-1808; NJ - B PO Box 3034 Mechanicsburg, PA 17055-1805; CO/NM/OK - B PO Box 3105 Mechanicsburg, PA 17055-1821; MD - B PO Box 3404 Mechanicsburg, PA 17055-1847; PA - B PO Box 3304 Mechanicsburg, PA 17055-1838; DCMA/DE - B PO Box 3405 Mechanicsburg, PA 17055-1848; MS - B PO Box 3128 Mechanicsburg, PA 17055-1833; TX - B PO Box 3106 Mechanicsburg, PA 17055-1822; AR/LA/MS - A PO Box 3103 Mechanicsburg, PA 17055-1819; PA/NJ/DC/MD - A PO Box 3385 Mechanicsburg, PA 17055-1840; DE - A PO Box 3417 Mechanicsburg, PA 17055-1853; JL - Feb 2011 Transition - A PO Box 3122 Mechanicsburg, PA 17055-1832; CO/NM/TX - A PO Box 3113 Mechanicsburg, PA 17055-1828; OK - A PO Box 3114 Mechanicsburg, PA 17055-1829. 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- Insufficient Data; 13- Patient Enroll HMO; 14- Svcs Not Rendered; 15- Medical Necessity; 16- Hospice; 17-Other-Please Specify: Description Required. 55200NS (09-25) Include listing of claims with Required Information with check.
A filled-in Novitas Form 8322 example: a provider refunds one duplicate claim
How to fill out Novitas Form 8322, box by box
Provider or Other Entity Name
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 Identifier Number (10 digits). Tax ID # - Provider Tax Identification 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.
Multiple Claims being refunded: If refunding multiple claims, list all claim numbers and the required data on separate forms if necessary.
Patient Name, Claim Number and Reason Code
For each claim the required fields to be completed on the form are noted with *. If the required fields for specific Patient/MBI & Claim Numbers are not completed, NO appeal rights can be provided for this voluntary refund.
Patient Name - Name of patient on claim for which money is being voluntarily returned (Required for Appeal rights). Medicare ID # - Medicare Beneficiary Identification # 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 specific claim listed. Date of Service From - Date services started for specific claim listed. Date of Service To - Date services ended for specific 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 specific claim listed. Additional Info. Field - To be populated when Reason Codes 01, 03, 08, 09, 10 or 17 are selected.
OIG Reporting Requirements
OIG Reporting Requirements - Select Yes or No to each question.
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
Medicare Secondary Payment (MSP) Refunds: Include a copy of the primary insurer's explanation of benefit (EOB) & indicate the MSP reason.
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. 55200NS (09-25)
More rules for Novitas Form 8322
The acceptance of a voluntary refund in no way affects or limits the rights of the Federal Government or any of its agencies or agents to pursue any appropriate criminal, civil, or administrative remedies arising from or relating to these or any other claims.
Sources
[1] Novitas Form 8322, Return of Monies Voluntary Refund Form (09-25), Novitas Solutions (the Official source link on this page).