Submit a Voluntary Refund - JF Part B

A voluntary refund is when an overpayment has been self-identified. A check is required to be submitted along with the appropriate form. The check will be applied to the identified overpayments. If there are excess funds, they will be applied per CMS Medicare Learning Network (MLN) Matters (MM) 3274.

There are two types of voluntary refunds Medicare Secondary Payer (MSP) and Non MSP.

1. MSP Voluntary Refund - Submit with a check and primary insurer Explanation of Benefit (EOB) such as Employer Group Plan, Workers Compensation and Auto/Liability.
   • Complete MSP Voluntary Checks Form in its entirety
     • Missing information may delay processing and could forfeit appeal rights
   • Indicate appropriate reason code for claim adjustment on MSP Voluntary Checks Form
   • Include a check along with primary insurer EOB
   • Mail MSP Voluntary Checks Form to address provided on form
     • Do not use this form for situations that involve Veteran's Administration (VA), Health Maintenance Organization (HMO), Pacific Medical Centers (PacMed) or USFHP (US Family Health Plan), these are all considered Non MSP
2. Non MSP Voluntary Refund - Submit with a check
   • Complete Non MSP Voluntary Checks Form in its entirety
     • Missing information may delay processing and could forfeit appeal rights
   • Indicate appropriate reason code for claim adjustment
   • Include a check
   • Mail Non-MSP Voluntary Checks Form to address provided on form

Avoid Processing Delays: Helpful Tips

• Do not include MSP and Non MSP voluntary refunds together on same check
• Submit correct voluntary refund with appropriate form
• Mail voluntary refund to correct PO Box provided on form