Overpayment Refund/Notification Form
Overpayment Refund/Notification Form
Please complete this form and include it with your refund so that we can properly apply the check and record the receipt. If a check is included with this correspondence, please make it payable to UnitedHealthcare and submit it with any supporting documentation.
Please select one (by checking the appropriate box): Immediate Recoupment of Payment
Refund Check Attached
Provider/Physician/Supplier Name
Contact Person and Phone #
Address Tax ID #
Check # Check Amount $
Check Date
REFUND INFORMATION
Please provide the following information for the claim being refunded. For multiple claims, print the attached spreadsheet with a list of all claim numbers involved.
Patient Name P
UnitedHealthcare Claim Audit #
Date of Service
Group #
Subscriber ID #
Claim Amount Refunded
Adjustment Reason Code ? One Reason Per Claim
If a specific patient or claim amount data are not available for all claims due to statistical sampling, please indicate methodology and formula used to determine amount and reason for overpayment.
Reason Codes: Billing/Clerical Error - 01 Corrected Date of Service ? 02 Duplicate - 03 Corrected CPT Code ? 04 Not Our Patient(s) ? 05 Modifier Added/Removed ? 06 Billed in Error - 07
Reason Codes: Insufficient Documentation ? 08 Patient Enrolled in HMO ? 09 Services Not Rendered ? 10 Medical Necessity ? 11 Non-Credentialed provider ? 12 Compliance Audit (Extrapolation Used) -13 Other (Please Specify):
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.
Mail to: UnitedHealthcare Insurance Company P.O. Box 101760 Atlanta, GA 30392-1760
Signature of Requestor:
UnitedHealthcare Insurance Company - Overnight Delivery Lockbox 101760 3585 Atlanta Avenue Hapeville, GA 30354
Date:
Rev. Jan 2019
This spreadsheet should be used to submit multiple refunds on an overpayment request from UnitedHealthcare. Please copy and paste this form to accommodate the information you need to submit.
Please supply all available information, including a claim audit number or the unique identifier listed/UID to help ensure the proper posting of your check. Additional documentation, such as a Provider Remittance Advice (PRA), is also helpful and should be submitted if available.
Please be specific when completing the Reason for Overpayment column and make sure your check total equals the claim totals identified. Thank you.
UID
Policy # Subscriber Member Member Provider Claim UnitedHealthcare First
Last Billed Refund Reason for Refund:
Number
First
Last Tax ID # Audit #
Check #
Service Service Amount Amount Overpayment Yes|No
Name
Name
Date
Date
Rev. Jan 2019
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- aarp s yankees contest official rules no purchase or
- consumer payment study survey questionnaire aarp
- overpayment refund notification form
- aarp and ncoa launch new resource as part of stimulus
- make your pledge in five easy steps
- aarp watchdog alert handbook
- electronic funds transfer printable receipt
- a guide to— understanding your aarp auto insurance policy
- struggling to make mortgage payments aarp
- aarp credit card from chase rewards program agreement
Related searches
- blackboard emergency notification system
- blackboard connect notification system
- wage garnishment notification requirements
- student loan overpayment refund
- garnishment notification to employee
- sample garnishment notification to employee
- employer wage garnishment notification letter
- garnishment notification letter to employee
- student loan overpayment billing direction
- payment notification template
- payment notification email
- garnishment notification letter