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Last Modified: 11/25/2017 Location: FL, PR, USVI Business: Part B
What form do providers use to notify Medicare of an MSP overpayment?
Q. What form do providers use to notify Medicare of an MSP overpayment?
A. When a provider determines that a Medicare overpayment exists, the following steps must occur.
Complete the Medicare Secondary Payer overpayment refund form
Florida providers click here for form pdf file
Puerto Rico providers click here for form pdf file
U.S. Virgin Islands providers click here for form pdf file
Provide a refund check
List all Medicare claim numbers included in the overpayment or a copy of the Medicare remittance notices with detailed claim information (Name, Medicare ID #, date of service, procedure code and billed amount)
Include the other insurer’s Explanation of Benefits (EOB) every claim involved. The other insurer’s EOB must have the insurer’s name and address.
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