Complete a Voluntary Refund

Table of Contents

• Forms Used for Providers NOT on Automatic Immediate Recoupments and Check(s) Are Attached to This Form(s)
• Option 1:
  • Completing the Voluntary Refund Form
  • High Volume Spreadsheet Instructions
• Option 2:
• Large Scale Overpayments

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Forms Used for Providers NOT on Automatic Immediate Recoupments and Check(s) Are Attached to This Form(s)

• Jurisdiction K CT-MA-ME-NH-NY-RI-VT
  • Jurisdiction K Part B Voluntary Refund Form
• Jurisdiction 6 IL-MN-WI
  • Jurisdiction 6 Part B Voluntary Refund Form

A voluntary refund is when a provider has self-identified an overpayment and a refund of excess funds is sent to National Government Services. All checks are made payable to National Government Services.

You may notify NGS of overpayments via two ways:

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Option 1:

Submit a check with the Jurisdiction 6 or Jurisdiction K Part B Voluntary Refund Form. When the claim(s) is adjusted, Medicare will apply the monies to the overpayment.

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Completing the Voluntary Refund Form

1. Complete the form in its entirety as missing information will delay processing.
2. Be sure the form is mailed to the appropriate address listed at the bottom of the form.
3. Include any additional documentation that would enable processing of the request.

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High Volume Spreadsheet Instructions

If you are sending a refund check that involves multiple (25 or more), high volume of claims, please use our Large Various Adjustment Macro (LVAM) Form. Save the excel spreadsheet to a CD or USB drive and mail it with your check and form: Jurisdiction 6 Part B Voluntary Refund Form or Jurisdiction K Part B Voluntary Refund Form. The mailing lockbox address is located at the bottom of the Voluntary Refund Form.

Be sure to include the password if you are sending a protected CD or USB drive, or supply a contact person who can retrieve the password.

NOTE: Please do not use this form when making payment in response to an overpayment demand letter. A check with the overpayment demand letter is all you need in that situation.

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Option 2:

Submit reopening via NGSConnex or Part B Reopening Request Form and NGS will create an account receivable, generate a forward balance remittance advice and demand letter.

Note: With option 2, if your organization is not set up for immediate offsets, you will need to follow up when you receive the NGS demand letter. For information on requesting an immediate offset, please see Request an Immediate Recoupment.

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Large Scale Overpayments

When submitting a request for correction of 25 or more for the same or similar situation, please complete a Part B Reopening Request Form and attach the Large Various Adjustment Macro (LVAM) Form. This form will help to ensure that the correct claims are identified for the adjustments being requested. This also prevents us from having to contact your office for further clarifications.

Revised 7/20/2023