Get Medicare Part B Msp Voluntary Checks Form - Jurisdiction E - Part ...

Filling out the Medicare Part B MSP Voluntary Checks Form is essential for providers/physicians who need to submit refund checks to Medicare. This guide provides clear steps to help users complete the form accurately and effectively online.

Follow the steps to fill out the Medicare Part B MSP Voluntary Checks Form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Start by filling in the required provider information, including the provider/physician or entity name, address, city, state, zip code, NPI number, and tax ID number.
3. Provide the contact person's name and telephone number, including the extension, if applicable. Also, enter the fax number.
4. In the check information section, input the check number and check date.
5. List details regarding the Medicare Secondary Payer by completing the required primary insurance information. Include the insurer's name, subscriber's name, policy number, group number, and the insurer's address.
6. If applicable, enter the injury diagnosis, state, and zip code, along with the injury date.
7. In the refund information section, fill out fields for each claim, such as the internal control number, beneficiary name, Medicare number, date of service, dollar amount to be refunded, procedure code, and reason code.
8. If there are additional claims, attach a separate spreadsheet with corresponding claim information.
9. Utilize the space provided for any extra information regarding claims adjustments.
10. Once all fields are completed, review the information for accuracy. You may then save changes, download the form, print a copy, or share it as necessary.

Complete your Medicare Part B MSP Voluntary Checks Form online today.