CMS Pub. 100-06, ch. 5, § 411.1

The term Medicare beneficiary identifier (Mbi) is a general term describing a

beneficiary's Medicare identification number. For purposes of this manual, Medicare

beneficiary identifier references both the Health Insurance Claim Number (HICN) and

the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition

period and after for certain business areas that will continue to use the HICN as part of

their processes.

SHALL BE COMPLETED BY MEDICARE CONTRACTOR

Date: ________________________________

Contractor Deposit Control # _____________Date of Deposit: _____________

Contractor Contact Name: ________________________ Phone #: _____________

Contractor Address: _________________________________________________

Contractor Fax: _____________________________________________________

________________________________________________________________________

______________

SHALL BE COMPLETED BY PROVIDER/PHYSICIAN/SUPPLIER, OR OTHER

ENTITY

Please complete and forward to your Medicare contractor. This form, or a similar

document containing the following information, should accompany every

unsolicited/voluntary refund so that receipt of check is properly recorded and applied.

PROVIDER/PHYSICIAN/SUPPLIER OR OTHER ENTITY NAME:

________________________________

ADDRESS: _____________________________________________________________

PROVIDER/PHYSICIAN/SUPPLIER #: _______________ TAX ID #:

______________

CONTACT PERSON: ______________________ PHONE #: _____________________

AMOUNT OF CHECK $: ___________ CHECK #: ___________ CHECK DATE:

______

REFUND INFORMATION

For each claim, provide the following:

Patient Name: ____________________________ Medicare beneficiary identifier:

_____________________

Medicare Claim Number: ___________________ Claim Amount Refunded $:

_________

Reason Code for Claim Adjustment: _______ (Select reason code from list below. Use

one reason per claim.)

(Please list all claim numbers involved. Attach separate sheet, if necessary)

Note: If Specific Patient/Medicare beneficiary identifier Amount data not available for all

claims due to Statistical Sampling, please indicate methodology and formula used to

determine amount and reason for overpayment:

________________________________________

NOTE: If specific patient Medicare beneficiary identifier information is not provided, no

appeal rights can be afforded with respect to this refund. Providers/physicians/suppliers,

and other entities who are submitting a refund under the OIG’s Self-Disclosure Protocol

are not afforded appeal rights as stated in the signed agreement presented by the OIG.

For Institutional Facilities Only:

Cost Report Year (s) ________________________

(If multiple cost report years are involved, provide a breakdown by amount and

corresponding cost report year.)

For OIG Reporting Requirements:

Do you have a Corporate Integrity Agreement with OIG? ___ Yes ___ No

Are you a participant in the OIG Self-Disclosure Protocol? ___ Yes ___No

________________________________________________________________________

______________

Exhibit 1 – Overpayment Refund Form (Cont.)

Reason Codes:

Billing/Clerical: MSP/Other Payer Involvement:

Miscellaneous:

01 – Corrected Date of Service 07 – MSP Group Health Plan Insurance 12 –

Insufficient Doc

02 – Duplicate 08 – MSP No Fault Insurance 13 – Patient

Enroll HMO

03 – Corrected CPT Code 09 – MSP Liability Insurance 14 – Svcs Not

Rendered

04 – Not Our Patient(s) 10 – MSP, Workers Comp. 15 –

Medical Necessity

05 – Mod. Add/Remove (Incl Black Lung) 16 – Other-

Please Specify

06 – Billed in Error 11 – Veterans Administration

_____________________