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 Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other names8322 novitas refund form

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

How to Edit Novitas Return Of Monies Form Online for Free

Managing files with our PDF editor is more straightforward in comparison with most things. To update Novitas Return Of Monies Form the document, you'll find nothing you should do - merely adhere to the steps down below:

Step 1: Click on the "Get Form Here" button.

Step 2: You can now edit your Novitas Return Of Monies Form. Feel free to use the multifunctional toolbar to add, remove, and change the content of the document.

Make sure you enter the next details to prepare the Novitas Return Of Monies Form PDF:

portion of spaces in Novitas Return Of Monies Form

Provide the appropriate data in the Do you have a corporate integrity, Are you a participant in the OIG, Note Providers and other entities, MSP Information, Other Insurer Information, Employer Information, Insurance Co Name, Subscriber Name, Insurer Address Line, Insurer Address Line, Employer Name, Employer Address Line, Employer Address Line, City, and State box.

Filling out Novitas Return Of Monies Form part 2

Step 3: The moment you select the Done button, your ready document is simply transferable to any of your devices. Or alternatively, you will be able to send it by means of email.

Step 4: Just be sure to create as many duplicates of the file as possible to prevent potential problems.

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