Get Request For Extended Repayment Plan - Palmetto Gba

Filling out the Request For Extended Repayment Plan - Palmetto GBA online is an essential step for healthcare providers seeking to manage overpayments effectively. This guide provides step-by-step instructions to ensure you complete the form accurately and submit all required documentation.

Follow the steps to successfully complete and submit your request.

1. Click ‘Get Form’ button to obtain the form and access it for completion.
2. Begin by filling out the 'Contact Information' section, ensuring all fields are completed thoroughly. This includes providing your contact name, phone number, email address, and preferred method of communication.
3. In the 'Provider Information' section, enter the required details such as provider name, address, and National Provider Identifier (NPI). Ensure that all information is accurate to avoid delays.
4. Next, complete the 'Overpayment Detail Information' section. Here, you must provide the overpayment amount, invoice number, date of the demand letter, and Provider Number (PTAN).
5. Specify the number of months you are requesting for the extended repayment plan. Be mindful of the maximum limit of 60 months.
6. If applicable, prepare and include the first payment submission instructions as outlined. Ensure that the check is made payable to Palmetto GBA, referencing 'ERS Request'.
7. Gather and attach all supporting documentation required for your request. This may include financial statements, tax returns, and letters from financial institutions.
8. Review all completed sections of the form and attached documents for accuracy. Once verified, you can save changes, download a copy of the form, print it, or share it as needed.

Complete your Request For Extended Repayment Plan - Palmetto GBA online today to manage your overpayment effectively.