MSP Post-Pay Overpayments

Forms You’ll Need

• Jurisdiction K CT-MA-ME-NH-NY-RI-VT
  • Medicare Part B MSP Overpayment Request Form
• Jurisdiction 6 IL-MN-WI
  • Medicare Part B MSP Overpayment Request Form
• JK or J6
  • Medicare Secondary Payer Part B Voluntary Refund Form

If you have received an overpayment because Medicare paid as the primary insurer and another insurance carrier should be the primary payer, follow the instructions on the Medicare Part B MSP Overpayment Request Form or or the Part B MSP Voluntary Refund Form.

• A separate refund form is needed for each date of service needing adjustment.
• The reason code area must be completed assigning the appropriate MSP provision to the overpayment (no fault, worker’s compensation etc.).
• Include the explanation of benefits from the primary payer with the overpayment request form or the voluntary refund form.

You have two options:

1. Submit a check with the Part B MSP Voluntary Refund Form. When the claim(s) is adjusted, Medicare will apply the monies to the overpayment.
2. Submit the Medicare Part B MSP Overpayment Request Form without a check and when the claim(s) is adjusted, Medicare will issue a demand letter.

Revised 6/8/2023