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

The Novitas Return of Monies form (IR20) is used to request a refund from an insurance company.

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Novitas Return Of Monies Form PDF Details

In case you have not heard, on September 8, 2016, Novitas Solutions released the Novitas return of monies form for Medicare Fee-For-Service (FFS) providers. The new form is designed to help providers receive payments for services provided to Medicare beneficiaries. In this blog post, we will go over how to complete the Novitas return of monies form and what to expect when submitting it. We will also provide a link to the form so that you can download it for yourself. Stay tuned for future blog posts that will provide more information on specific sections of the Novitas return of monies form.

We have compiled some quick information about the novitas return of monies form. Before you fill in the form, it is worth examining a little more about it.

Question	Answer
Form Name	Novitas Return Of Monies Form
Form Length	3 pages
Fillable?	Yes
Fillable fields	38
Avg. time to fill out	8 min 21 sec
Other names	8322 novitas refund form

12

Form Preview Example

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. field
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

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:

State - LOB	PO Box	City	State	ZIP
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

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

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portion of spaces in Novitas Return Of Monies Form

Provide the appropriate data in the MSP, Information Other, Insurer, Information Insurance, Co, Name Subscriber, Name Insurer, Address, Line Insurer, Address, Line Employer, Information Employer, Name Employer, Address, Line Employer, Address, Line City, State, Zip, City, and State box.

Filling out Novitas Return Of Monies Form part 2

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