Clear Form Print Form Provider Overpayment Disclosure Form PROVIDER INFORMATION Provider (agency) name: Provider contact first name: Last name: Provider ID/Service Location (PID/SL): NPI: City: State: Zip: Physical address: City: State: Zip: Mailing address: Office telephone number: Ext: Fax number: E-mail address: REASON FOR OVERPAYMENT (Check all that apply.) Collection from Medicare Part A Provider billed incorrect service date. Collection from Medicare Part B Erroneous duplicate payment for the same service date Collection from Medicare (not known if Part A or B) Provider billed for the service twice. Collection from auto insurance or workers' compensation insurance Collection from credit balance on patient account Collection from commercial health insurance Provider performed only a component of the entire service billed. Claim was paid to the wrong provider. Provider billed incorrectly. Cost report issues Other (specify): Wrong MassHealth member ID was on the claim. 1. Please provide written, detailed information about the overpayment(s). In the space below, describe the facts and circumstances surrounding the possible fraud, waste, abuse, or inappropriate payment(s) and its discovery, the period involved, and an assessment of the potential financial impact. Attach additional sheets, if needed. 2. Cite the MassHealth regulations or policies potentially implicated or violated. Enter "not known" if you do not know. Attach additional sheets, if needed. ODF (03/12) (over ) 3. Identify the underlying cause(s) of the issue(s) involved, specify the nature and extent of any investigation or audit you conducted to identify the overpayment, describe any corrective action taken to address the problem leading to the overpayment, and identify the date the correction occurred and the process for monitoring the issue to prevent recurrence. Attach additional sheets, if needed. 4. Identify the individuals involved in any suspected improper or illegal conduct. Attach additional sheets, if needed. First name: Last name: Title/Position: First name: Last name: Title/Position: First name: Last name: Title/Position: 5. Provide a list of claims that comprise the overpayments. For each claim, provide the member's name and MassHealth ID number, the claim ICN and line detail number, date of service, service code, modifier, units, amount paid by MassHealth, amount paid by a third-party liability (TPL) insurer, and the amount of the overpayment. If there are more than five claims, then the claims must be formatted in an Excel spreadsheet or Access database and transmitted via secure e-mail, or placed on an encrypted CD and mailed with this form. Member name: Member ID: ICN: Line detail: Dates of service: Service code: Modifier: Units: Paid amount: TPL: Overpayment: Member name: Member ID: ICN: Line detail: Dates of service: Service code: Modifier: Units: Paid amount: TPL: Overpayment: Member name: Member ID: ICN: Line detail: Dates of service: Service code: Modifier: Units: Paid amount: TPL: Overpayment: Member name: Member ID: ICN: Line Detail: Dates of service: Service code: Modifier: Units: Paid amount: TPL: Overpayment: (over ) Member name: Member ID: ICN: Line Detail: Dates of service: Service code: Modifier: Units: Paid amount: TPL: Overpayment: 6. If applicable, provide the primary payor health insurance information. If there is more than one member, then the information must be formatted in an Excel spreadsheet or Access database and transmitted via secure e-mail, or placed on an encrypted CD and mailed with this form. Member name: Member ID: Policyholder name: Policy no: Employer name: Group no: Insurance company name: Address: City: State: Zip: Telephone number: Fax number: E-mail address: List below any family members who are on the health insurance policy: 1. 4. 2. 5. 3. 6. 7. If applicable, provide information about any federal or state agency involvement. State or federal agency and/or law enforcement notified: State Federal Law enforcement Other (Specify): Agency notified: Date notified: Contact person: Title: Address: City: State: Zip: Telephone number: Fax number: E-mail address: 8. Provide your contact information. Contact person: Title: Address: City: State: Zip: Telephone number: Fax number: E-mail address: (over ) I certify under the pains and penalties of perjury that the information on this form and any attached statement that I have provided has been reviewed and signed by me, and is true, accurate, and complete, to the best of my knowledge. I also certify that I am the provider or, in the case of a legal entity, duly authorized to act on behalf of the provider. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein. Signature of provider or authorized representative (if legal entity) (Signature and date stamps, or the signature of anyone other than the provider or a person legally authorized to sign on behalf of a legal entity are not acceptable.) Printed legal name of provider Printed legal name of authorized representative and person's title (if the provider is a legal entity) Date Mail the completed Provider Overpayment Disclosure Form to MassHealth at the address below. MassHealth--Provider Compliance Unit 529 Main Street, Schraffts Center Box #26, 3rd Floor, Suite 320 Charlestown, MA 02129-1120 In addition to mailing the completed Provider Overpayment Disclosure Form, the provider is urged, in the interest of time expediency, to e-mail the completed form to providercomplianceunit@umassmed.edu. Providers should take precautions appropriate for the transmission of personal information and, in no case, should member names and MassHealth identification numbers or social security numbers be transmitted without using secure e-mail. MassHealth recommends that providers use a secure e-mail site to encrypt all electronic communications. If providers do not have access to a secure e-mail site and would like to use the one maintained by the MassHealth Provider Compliance Unit to transmit personal information or to transmit the Provider Overpayment Disclosure Form, they should send an e-mail requesting access instructions to providercomplianceunit@umassmed.edu.