Overpayment Notification/Refund Form

Web Content Viewer

Actions

Web Content Viewer

Actions

Overpayment Notification/Refund Form

Published on Mar 12 2018, Last Updated on Apr 06 2020

← back-to-previous-page

Jurisdictions: J8A,J5A,J8B,J5B,Overpayment,Overpayment Forms,Forms

In the event you have identified an overpayment or need to return funds, WPS GHA offers two solutions to complete your desired outcome:

Portal - WPS GHA recommends providers use the portal to complete claim adjustments, and return funds for fast, efficient processing. If you are not currently a portal user, we recommend signing up today.

Form - If you choose not to use the WPS GHA portal, we do have a fillable form available for use. Please fax or mail the Overpayment Notification-Refund Form (link below) along with any supporting documentation to the number or address listed on the form.

We process overpayments submitted through the portal within 24 hours.
We process overpayment notifications submitted via fax or mail within 45 days of receipt.
Ensure your request is on the most current form (version) available on our website.
You must submit one form for each Medicare claim number. Do not include multiple Medicare claim overpayments on one form.
Fill out each field of the form as complete and accurate as possible. We need complete and accurate information to process your request efficiently.
If the reason for the overpayment or refund is a result of a primary or secondary insurance coverage, you must submit an explanation of benefits (EOB) from the insurance provider.
Once we have processed the overpayment notification form, the claim adjustment will appear on your remittance with a PLB reason code, forwarding balance (FB) indicator. This is not a recoupment or offset, which would show up on the remittance as an overpayment recovery (WO) indicator.
You can find detailed information about the overpayment on your remittance (i.e. date of service, beneficiary name), in the WPS GHA Portal, or by comparing the remittance financial control number (FCN) to the invoice number on the demand letter. If you are unable to locate the needed information, please contact WPS GHA Customer Service.
After we issue a demand letter, the provider will have 30 days to refund any money due to avoid interest payments.
- Immediate recoupment - Providers have the option after receiving their demand letter to request an immediate recoupment. The request can be for a specific demand letter or as a permanent request for all future overpayments. They may do this by filling out the Immediate Recoupment Request form.
  - Requesting an immediate recoupment does not eliminate interest payments when the accounts receivable (amount due) is not offset in full within 30 days.
- E-refund – You can complete an e-refund using the WPS GHA Portal.
- Mailing a physical check with the completed form.

Specific to Refunds

The Office of the Inspector General (OIG), working with the Department of Justice and CMS, created two initiatives to help combat health care fraud and abuse and to encourage providers to comply with Federal health care program regulations. Both initiatives are designed to ensure that the providers/suppliers refund inappropriately received Medicare monies back to the trust funds:

OIG Self-Disclosure Protocol
Corporate Integrity Agreements (CIAs)

The OIG produced the OIG Self-Disclosure Protocol to provide guidance to health care providers/physicians/suppliers and other entities that decide to voluntarily disclose irregularities in their dealings with the Federal health care programs. The decision to follow the OIG Self-Disclosure Protocol rests exclusively with the provider/physician/supplier and other entity. The intent of the OIG Self-Disclosure Protocol is to facilitate the resolution of only matters that, in the provider/physician/supplier and other entity’s reasonable assessment, potentially violates Federal, criminal, civil, or administrative laws. Providers/physicians/suppliers and other entities who self-disclose to the OIG sign an agreement stating that any refunds submitted as part of the self-disclosure process are not subject to appeal.

Healthcare providers/suppliers enter into a Corporate Integrity Agreement with OIG as part of a global settlement of a fraud investigation. The CIA (which can be for a period ranging from three to five years) requires the provider/supplier to undertake specific compliance obligations, such as designating a compliance officer, undergo training, and auditing. The provider/supplier must report regarding their compliance activities on an annual basis to OIG, which is responsible for monitoring the agreements.

WPS GHA will deposit any voluntary refund checks within 24 hours of receipt and will apply the appropriate amount against any established account(s) receivable. We will then make adjustments to the claims and/or the claim history file for the identified claims. The exception to this standard accounting practice is for checks with conditional endorsements which are statements intended to imply that the deposit of the check will clear the sender's account. Statements such as "payment in full" or "paid in full" written on the check or accompanying correspondence may not, in fact, discharge the debt to Medicare. We will send the below information to the provider in the event they included any conditional statements on the check:

"This is to acknowledge the receipt of the repayment in the amount of $XX, check number XX. The matter is being investigated, however, the amount of the repayment may be insufficient to discharge the obligation and the debt may not be fully extinguished."

Acceptance/deposit of the voluntary refund check in no way limits the rights of the Federal Government or any of its agents to pursue any appropriate criminal, civil, or administrative remedies arising from or relating to these or any other claims.

Breakdown of the Overpayment Notification/Refund Form

Contract – choose J5 for Iowa, Kansas, Nebraska, or Missouri; choose J8 for Indiana or Michigan.
Medicare Type – choose Part A or Part B.
State – enter the two alpha characters for the state in which you performed the service.
Billing Provider Name – enter the name of the individual/group who received payment for the service.
Address – enter the provider practice address.
Billing PTAN – enter the PTAN of the individual/group who received payment for the service.
Billing NPI – enter the NPI of the individual/group who received payment for the service.
TIN – enter tax identification number for the individual/group who received payment for the service.
Contact Person – enter the name of the person who we can contact for additional information.
Phone Number – enter the phone number where we can reach the contact person.
Patient Name – enter the patient name involved with the inquiry.
Medicare ID – enter the Medicare Beneficiary Identifier of the patient in question.
Medicare Claim Number – enter the claim number listed on the Remittance Notice in question.
Date of Service – enter the date you provided the service.
Procedure Code – enter the procedure code of the service you provided.
Overpaid Amount – enter the amount overpaid.
Reason for Overpayment – choose the best reason for the overpayment. When choosing “Non-MSP – Other, please specify,” please explain the reason in the “Explanation” field.
Explanation (if necessary) – only used when choosing “Non-MSP – Other, please specify” as your reason for overpayment.
Cost Report Year(s) – enter the year or years in which the overpayment belongs.
* Amount of Payment – enter the amount of the check you enclosed with the form.
* Check # - enter the number listed on the check you enclosed with the form.
* Check Date – enter the date you wrote on the check you enclosed with the form.
Refund is the result of – choose the best description for the reason. If this is not due to an OIG Self Disclosure or Corporate Integrity Agreement, choose “Neither.”

* Only fill in these fields if you submitted payment with your Overpayment Notification/Refund Form

global-tags: J8A,J5A,J8B,J5B,Overpayment,Overpayment Forms,Forms

Attached File

overpayment-notification-refund-form.pdf | 62 KB

Download File

Web Content Viewer

Actions

NPI_MODAL_PART_B_TITLE	NPI_MODAL_PART_A_TITLE
J5B RADIO NPI_MODAL_J5B_RADIO	J5A RADIO NPI_MODAL_J5A_RADIO
INB NPI_MODAL_INB_RADIO	NTA NPI_MODAL_NTA_RADIO
MIB NPI_MODAL_MIB_RADIO	INA NPI_MODAL_INA_RADIO
	MIA NPI_MODAL_MIA_RADIO

Overpayment Notification/Refund Form

Need help?

Need help?

Need help?

Need help?

Need help?

Need help?

Need help?

Need help?

Need help?

Need help?

Overpayment Notification/Refund Form

global-tags: J8A,J5A,J8B,J5B,Overpayment,Overpayment Forms,Forms