Recovery Auditor Offset Form Instructions

To streamline processing of offset requests related to Recovery Auditor overpayments, Noridian has created a unique offset request form and established a dedicated fax line to receive these requests.

The Offset Request - DME Recovery Auditor form is designed for use ONLY when requesting that future claims payments be applied to overpayments that were initiated by Health Data Insights (HDI).

Offset requests for more than one Recovery Auditor overpayment may be included on one Offset Request - DME Recovery Auditor form, but only if the supplier number is the same on all of the overpayments. A copy of the overpayment letter from HDI should be faxed with the request.

Follow the instructions below when completing the Offset Request - DME Recovery Auditor form. Please type or print clearly.

Supplier Information

  • Supplier PTAN - Supplier's Provider Transaction Access Number
  • Supplier NPI - Supplier's National Provider Identification Number
  • TIN (last 5 digits) - Supplier's TIN or at least the last five digits of the TIN
  • Supplier Name - Supplier's complete name
  • Contact Name - Name of individual that Noridian staff may call with questions
  • Supplier Phone Number - Contact's phone number and extension

Overpayment Information

In order to ensure correct processing, the Accounts Receivable Number and Supplier Overpaid Amount must be included for each offset requested. The Beneficiary Name, Health Insurance Claim Number, date of service, and Claim Control Number (CCN) are requested but are not mandatory.

  • Accounts Receivable Number: Number referenced on the overpayment letter from HDI
  • Supplier Overpaid Amount: Amount of the overpayment to be offset.
  • Beneficiary Name: Full name of the beneficiary
  • Beneficiary's Medicare ID
  • Date of service
  • Claim Control Number (CCN): Claim number

Other information

For information on how to request an offset on a non-Recovery Auditor-related overpayment, see Refunds to Medicare Process.

Last Updated Dec 08 , 2023