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March 27, 2018

Attention: Top Ten Tips for the Correct Completion of CGS Overpayment Recovery Request Form

It is important to fill out the Overpayment Recovery Request formPDF correctly to avoid processing delays.  Be sure to review these tips prior to submitting the form.

  1. Submit one claim per form.
  2. Include the Medicare remittance notice that contains the claim in question with the form.
  3. Select only ONE state – Kentucky or Ohio
  4. Select only ONE type of overpayment – NON-MSP or MSP
  5. For NON-MSP overpayments ONLY complete the section of the form entitled REASON FOR  NON-MSP Overpayment
  6. Only select ONE reason for the NON-MSP Overpayment
  7. FOR MSP overpayments ONLY complete the section of the form entitled Reason for Overpayment: MSP.  If Auto, Liability or WC is checked, include the date of injury to avoid delays!
  8. Only select ONE reason and include a copy of the primary payer Explanation of Benefits (EOB) or payment information.  Be sure the address of the primary carrier is included in the information. .
  9. FAX the completed form and additional information for Kentucky claims to 615-664-5916
  10. FAX the completed form and additional information for Ohio claims to 615-664-5926

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