Voluntary Overpayment Refund Form

Form Instructions

A Voluntary Overpayment Refund form should accompany any refunds submitted to a third party payer. This general form is one that could be used within your practice.

PURPOSE:

Post-payment reviews are now a part of the reimbursement process. As a result, these reviews often result in a payer determining that a claim was paid in error. When a payer discovers this overpayment, generally a letter is sent to the provider explaining the situation along with the amount owed and the date that a refund is due

ALERT: Always check the payer's website to see if they have a specific form that should be used to accompany overpayment refunds. For example, Medicare Administrative Contractors have required forms, but the forms are different for different jurisdictions as well as the type of plan (i.e. Part B, DME).

File Size: 83.64 KB

File Type: .pdf - PDF file

File Name: Sample-Voluntary-Overpayment-Refund-form.pdf