myCGS

Forms

Overpayment Recovery Request (Part B)

Part B providers may submit an Overpayment Recovery Request to notify us of an overpayment. Doing this will generate a demand letter identifying the amount to be refunded.

Once the request is received, approved, and processed, we will issue an overpayment demand letter. The debtor has 30 days from the date of the demand letter to submit the refund. (See Immediate Offset in the Financial Tools section of this user manual to avoid delays and possible interest added to the principal balance.)

After clicking the form link the Overpayment Recovery Request form will display. Required fields are identified by a RED asterisk (*). For your convenience, some fields of the form are pre-populated with information specific to your myCGS User ID and PTAN/NPI combination.

Verify/complete the PROVIDER INFORMATION section. Add your phone number in the appropriate field. NOTE: Should we need to contact you with questions about your request, please be sure to enter a number to a direct line to reach you.

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Complete the BENEFICIARY INFORMATION section by entering the patient's name and Medicare ID.

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Complete the CLAIMS INFORMATION section by entering the claim Internal Control Number (ICN). The ICN is located on your CGS Remittance Advice (RA). Also, select the option to identify whether this request is related to Medicare Secondary Payer (MSP) or not related to MSP (NON-MSP).

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  • MSP: If MSP is involved, click the drop-down box under Type and select the appropriate value. If none apply, select Other and a box will display allowing you to enter text identifying the specific reason for your request. Also, complete the Line and Date of Service fields.
    • Under the Line drop-down, select the applicable claim line number. If this applies to all lines of the claim, scroll to bottom of drop-down and select ALL.
    • Enter the primary payer allowed and paid amounts, and the "Obligated to Accept" amount (if the provider has contracted with the primary insurance company and is obligated to accept their allowed amount for the service). Also, enter the From and To date of service.
    • Click ADD to insert this line onto the form.
    • Once the line is added to the form, you may:
      • Add additional lines from the claim (unless ALL is selected)
      • Delete a line added to the form by selecting the red 'X' in the last column.
      • Complete the request.



  • NON-MSP: If MSP is NOT involved, click the drop-down box under Type of Adjustment to identify if the overpayment applies to a single line of the claim or the entire claim.

    • If the overpayment applies to the entire claim, under the Type drop-down, select the reason the overpayment occurred. The remaining fields (Action and Line) will auto-populate.
    • If the overpayment applies to a specific line(s) of the claim and not the entire claim, under the Type drop-down, select the reason the overpayment occurred. If none apply, select Other and a box will display allowing you to enter text identifying the specific reason for your request.
    • Select appropriate value under the Action drop-down. Values vary depending on what was selected under the Type drop-down. The option under Action is DENY for all types except:
      • Corrected # of Units: The value is REPLACE.
      • Corrected Date of Service: The value is REPLACE.
      • Corrected Procedure Code: The value is REPLACE.
      • Modifier: The values are ADD, REMOVE, or REPLACE.
    • Under the Line drop-down, select the applicable claim line number. If this applies to all lines of the claim, scroll to bottom of drop-down and select ALL.
    • The Position drop-down displays only when Modifier is selected under the Type field. In this case you would identify the position of the modifier.
    • The New Value field is required when the following are selected under the Type field:
      • Corrected # of Units: Enter the correct number of units.
      • Corrected Date of Service: The field changes to FROM/TO DATE OF SERVICE. Enter the correct date of service.
      • Corrected Procedure Code: Enter the correct procedure code.
      • Modifier: When ADD or REPLACE is selected under Action. Enter the correct modifier.
    • Click ADD to insert this line onto the form.


    • Once the line is added to the form, you may:
      • Add additional lines from the claim (unless ALL is selected)
      • Delete a line added to the form by selecting the red 'X' in the last column.
      • Complete the request.

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