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Get How To Fill Medicare As Secondary Adjustment Form

Part A MSP P.O. Box 11465 Birmingham, AL 35202-1465 MSP Adjustment Cahaba GBA Medicare Secondary Payer (MSP) Adjustment Form Part A Provider Information: Name: NPI/PTAN Provider #: Address: Phone #: Beneficiary Information: Name: Medicare #: Phone #: Overpayment/Underpayment Amount: Internal Control Number (ICN): Service Date: Reason for Request: (Select all that apply) Overpayment (Reminder: If the Overpayment amount is not equal to the Medicare paid amount, a primary Explanation.

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