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.

QuestionAnswer
Form NameNovitas Return Of Monies Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names

Form Preview Example

NOVITAS SOLUTIONS - Part B

RETURN OF MONIES TO MEDICARE

MEDICARE

PART B

 

 

Date form is being completed:

 

 

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

AR - PO Box 890091, Camp Hill, PA 17089-0091

PA - PO Box 890304, Camp Hill, PA 17089-0304

DCMA/DE - PO Box 890405, Camp Hill, PA 17089-0405

LA - PO Box 890090, Camp Hill, PA 17089-0090

MD - PO Box 890404, Camp Hill, PA 17089-0404 NJ - PO Box 890034, Camp Hill, PA 17089-0034

MS - PO Box 890128, Camp Hill, PA 17089-0128

TX - PO Box 890106, Camp Hill, PA 170890106

CO/NM/OK - PO Box 890105, Camp Hill, PA 17089-0105

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.

8322 (R11-12)

Camp Hill, PA 17089 www.novitas-solutions.com

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