Overpayment Refund Form
When you identify a Medicare overpayment use the Overpayment Refund Form to submit the voluntary refund. This will ensure we properly record and apply your check. Always complete the physician/refund portions and use the reason codes listed on the bottom of the form to identify the reason for your refund. When refunding for multiple beneficiaries, please be sure to include sufficient documentation to show how much money is being refunded for each claim. We also recommend, but it is not required, that you refund no more than 20 beneficiaries per check. In addition, below are some other helpful tips we recommend, but are not required, when sending refunds to Medicare:
- Send separate checks for overpayments previously requested from those that are being voluntarily refunded.
- Send separate checks for beneficiaries being refunded due to MSP from those being refunded due to Non-MSP.
- When refunding due to MSP, please be sure to include the primary insurance’s explanation of benefits. This is needed in order to determine the correct primary insurance allowed and paid amounts.
Mail your check and the Overpayment Refund form along with any other documentation to:
Idaho CIGNA Government Services |
North Carolina CIGNA Government Services |
Tennessee CIGNA Government Services |
