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Name: Provider refund
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Provider Refund Return. Please complete this form and include it when returning overpayments made payable to Blue Cross and Blue Shield of North Carolina. Indicate name, address, and amount paid by other carrier. – “Overpayment” Blue Cross payment in excess of amount billed; provider has posted a credit for supplies or services not rendered; provider cancelled charge for any reason; or claim incorrectly paid per contract. PROVIDER REFUND FORM. Use this form when submitting a refund check to Home State Health. Provider Name & Provider Tax ID#. Member Name. Claim(s )#.
Please use this form to submit your refund should you receive an overpayment from ConnectiCare, Inc. Provider Name: Date: Provider ConnectiCare ID: Address: The following information must be completed for each refund. Complete this form when your office determines an overpayment has been made on one of your patients. It is not necessary to call Customer Service prior to. Paid Wrong Provider (Payment sent to wrong address or TIN) claim, please use Provider Refund Form – Single Claim, which can also be found at www.
To ensure your refund is handled appropriately, we request that you complete the Provider Refund Claim Form in its entirety. If your refund contains more than. Reason for refund. □ Other insurance (attach primary EOB). □ Subrogation. □ Duplicate payment. □ Claim was processed under the incorrect provider. 1, NCTracks Provider Refund Request Form. 2, How to submit a refund: 3, Complete Refund Request Form, Refund Contact Name. 4, --Please itemize dates of. PROVIDER REFUND RETURN. Please complete this form when returning overpayments to the Blue Cross and Blue Shield of North Carolina. This will help us. NOTE: It is not necessary to return the original check and the entire remittance advice/explanation of payment if just one or two patient claims are paid incorrectly.
Overpayment refunds will go directly to a secured bank lock box to maintain the accuracy and timeliness of applying refund checks. 1. Provider Name. 30 Jun In an effort to provide consistency in provider refund requests, a new form has been developed and posted to the NCTracks website. Providers. Refund Form. Instructions for Providers: Gateway cannot accept verbal requests to retract claim(s) overpayments. Providers may complete and submit a Refund. ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER INQUIRY/REFUND/ ADJUSTMENT FORM. Date: Underpayment Overpayment Corrected Claim.