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Overpayment Refund Form

When you identify a Medicare overpayment, use the Overpayment Refund FormPDFto submit the voluntary refund. This will ensure we properly record and apply your check.

NOTE: Type directly into the required fields on the Overpayment Refund Form, then print. Illegible forms may cause a delay in processing.

Below are some other helpful tips when sending refunds to Medicare:

  • Always complete the physician/refund portions and use the reason codes listed on the bottom of the form to identify the reason for your refund.
  • When refunding for multiple beneficiaries, please be sure to include sufficient documentation to show how much money is being refunded for each claim.
  • We recommend that you refund no more than 20 Internal Claim Numbers (ICN, also called CCN) per check.
  • Send separate checks for overpayments previously requested (demand letters) from those that are being voluntarily refunded.
  • Send separate checks for beneficiaries being refunded due to Medicare Secondary Payer (MSP) from those being refunded due to Non-MSP.
  • When refunding due to MSP, please be sure to include the primary insurance's explanation of benefits. This is needed in order to determine the correct primary insurance allowed and paid amounts.

Mail your check and the Overpayment Refund formPDF along with any other documentation to (please address to "MSP Overpayment Recovery" if for MSP):

Mailing Address for refund checks:

CGS – J15 Part B Kentucky
PO Box 957065
St. Louis, MO 63195-7065

CGS – J15 Part B Ohio
PO Box 957352
St. Louis, MO 63195-7352

Telephone: 1.866.276.9558
KY OPR Fax: 615.664.5916
OH OPR Fax: 615.664.5926

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