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 |
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| Form Name | Novitas Return Of Monies Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names |
NOVITAS SOLUTIONS - Part B
RETURN OF MONIES TO MEDICARE
MEDICARE
PART B
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Date form is being completed: |
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MAIL TO: Novitas Solutions - CASHIER. Please select the address according to the state you rendered services: |
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AR - PO Box 890091, Camp Hill, PA |
PA - PO Box 890304, Camp Hill, PA |
DCMA/DE - PO Box 890405, Camp Hill, PA |
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LA - PO Box 890090, Camp Hill, PA |
MD - PO Box 890404, Camp Hill, PA |
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MS - PO Box 890128, Camp Hill, PA |
TX - PO Box 890106, Camp Hill, PA 170890106 |
CO/NM/OK - PO Box 890105, Camp Hill, PA |
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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 |
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 |
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NPI NUMBER |
*BENEFICIARY NAME (Patient) |
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PROVIDER / PHYSICIAN / SUPPLIER NAME |
BENEFICIARY ADDRESS |
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PROVIDER / PHYSICIAN / SUPPLIER ADDRESS (Street, City, State, Zip Code) |
PROVIDER / PHYSICIAN / SUPPLIER REFUND CHECK NUMBER |
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PROVIDER OFFICE CONTACT TELEPHONE NUMBER |
PROVIDER / PHYSICIAN / SUPPLIER REFUND CHECK DATE |
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BILLING OFFICE CONTACT NAME & TELEPHONE NUMBER |
PROVIDER / PHYSICIAN / SUPPLIER TAX ID NUMBER |
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*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 |
BothClaim Number/ICN's
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EMPLOYER INFORMATION (MSP): |
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OTHER INSURER INFORMATION (MSP): |
Name: |
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Name: |
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Address: |
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Address: |
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City/State/Zip: |
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City/State/Zip: |
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Telephone # (if available): |
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Telephone # (if available): |
Subscriber/Member/Policy #: |
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Please return this completed form with your remittance. |
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8322 |
Camp Hill, PA 17089 • |