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Get Medicare Secondary Payer Adjustment Form Part B

Art B MSP P.O. Box 12724 Birmingham, AL 35202-6724 MSP Adjustment Cahaba GBA Medicare Secondary Payer (MSP) Adjustment Form Provider Information: Name: NPI/PTAN Provider #: Address: Phone #: Beneficiary Information: Name: Medicare #: Phone #: Service Date: Overpayment/Underpayment Amount: Internal Control Number (ICN): Reason for Request: (Select all that apply) Overpayment (Reminder: If the Overpayment amount is not equal to the Medicare paid amount, a primary Explanation of Benefits (EO.

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