Get Overpayment Refund Notification Form - Empire Blue

This guide provides detailed instructions for completing the Overpayment Refund Notification Form for Empire Blue online. By following these steps, you can ensure that your overpayment refund request is submitted accurately and efficiently.

Follow the steps to complete the Overpayment Refund Notification Form online.

1. Press the ‘Get Form’ button to access the Overpayment Refund Notification Form and open it in your preferred editor.
2. Begin by entering the provider name and contact information in the designated fields. This includes the provider's contact number.
3. Fill in your Provider ID and Tax ID numbers clearly to ensure accurate identification.
4. Input the Subscriber ID associated with the member requiring the refund.
5. Locate and record the DCN number, which is displayed on the Cost Containment Unit letter, in the specified field.
6. Provide the member's name and account number to associate the refund with the correct member.
7. State the date of service for which the refund request is being made.
8. Enter the total billed charges and the total check amount being submitted for the refund.
9. List the claim number(s) related to the overpayment, ensuring you include all pertinent claim identifiers.
10. Indicate the reason for the refund or check return by checking the applicable boxes or writing in an 'Other' reason if necessary.
11. After filling out all the necessary information, review the form for accuracy before saving changes.
12. You can download or print the completed form, and remember to mail it along with all necessary refund checks to the address specified in the instructions.

Submit your Overpayment Refund Notification Form online to initiate your refund process today.