Novitas Return Of Monies Form – Fill Out and Use This PDF

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.

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.

55200NS

Instructions

•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.

•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 benefit (EOB) & indicate the MSP reason (see Reason Code List Below)

•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

Make check payable to Medicare Part A or Medicare Part B. Mail to Novitas Solutions CASHIER at Address listed below according to state services rendered:

Reason Codes for each Claim Incorrect Payment (Required to Select One Reason code per refunded claim on Form):

55200NS

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. 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 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 – 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

55200NS