Request an Immediate Recoupment

Forms You’ll Need

These forms apply to providers that are NOT on Automatic Immediate Recoupments.

Electronic Submissions

JK or J6 Immediate Recoupment Request Form - Electronic/E-mail

Paper Submissions

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

Providers ON Automatic immediate Recoupments

Do nothing as this automation process will automatically be done and will be reported back to you with an updated RA.

National Government Services has implemented a standardized “immediate recoupment” process that gives you the option to avoid interest from accruing on claims overpayments when the debt is recouped in full prior to or by the 30^th day from the initial demand letter date.

The immediate recoupment process allows you to request that recoupment begin prior to day 41. By selecting this option, providers/suppliers may avoid paying interest if the overpayment is recouped in full prior to or by the 30^th day from the initial demand letter date.

An “immediate recoupment” is considered a voluntary repayment and will not be subject to 935 (f)(2) interest pursuant to Section 1893(f)(2). The request may be for the following:

A one-time request for all current overpayment(s) addressed in the reference demand letter and all future overpayments.
A request for all current overpayment(s) addressed in the referenced demand letter only.
A request to terminate a previously established immediate recoupment agreement.

You can submit your request by fax, or by using the Immediate Recoupment Request - Electronic/Email Form. Note: You can terminate the immediate recoupment process at any time; however, the request to terminate must be in writing. To request an immediate recoupment by fax, you must complete the Immediate Recoupment Request Form.

A request for immediate offset must be received no later than the 16^th day from the date of the initial demand letter.

Immediate recoupment forms can be found on the NGSMedicare.com website under the Forms tab. Click on “Overpayments” to access these forms.

Once you complete and submit the Immediate Recoupment Request - Electronic/Email Form, you will receive a confirmation email of your submission. Once you receive your confirmation email, no additional follow-up notices will be issued regarding your request. Any money recouped through the immediate recoupment process (i.e., fax, electronic/email form) will be indicated on your remittance advice. When there is a remaining principal balance after the initial immediate recoupment, National Government Services shall continue recoupment and other collection activities.

If you have already submitted a request for all future recoupments, you no longer need to request an immediate recoupment for each demand letter you receive.

Revised 6/8/2023