Get Medicare Je Part B Non-msp Voluntary Checks Form

Filling out the Medicare JE Part B Non-MSP Voluntary Checks Form is essential for processing voluntary refund requests. This guide will provide clear instructions to help users accurately complete the form online, ensuring a smooth submission process.

Follow the steps to accurately complete your form online.

1. Press the ‘Get Form’ button to access the form and display it in the designated editor.
2. Select the appropriate state code where services were rendered by checking the corresponding box for NO. CAL, SO. CAL, NV, HI, AS, MP, or GU.
3. Fill in your Provider/Physician or entity name, along with the address details, including city, state, and zip code.
4. Provide your Provider/Physician and/or NPI Number and Tax ID# in the specified fields to ensure identification.
5. Complete the contact person information, including their name, telephone number, and fax number, ensuring that you add the appropriate extensions.
6. Fill in the check details, including the check number and check date, making sure these are accurate.
7. Select the reason for the refund based on the given options relevant to OIG reporting requirements.
8. For each claim, enter the required information such as Internal Control Number (ICN), Medicare Number (HIC), beneficiary name, date of service, total dollar amount to be refunded, procedure code to be refunded, and reason code.
9. If needed, indicate any changes to CPT codes under sections 3A and 3B, and provide additional comments in the space for adjustments.
10. Review all information provided to ensure accuracy, as missing details can affect appeal rights.
11. Finally, save any changes made, and you can choose to download, print, or share the completed form for submission.

Complete your Medicare JE Part B Non-MSP Voluntary Checks Form online today!