Explanation Of Check Refund Mail To Arkansas Medicaid Refunds

explanation of check refund mail to: arkansas medicaid refunds po box 8181 little rock, ar 72203 provider name

Explanation of Check Refund
Mail To:
Arkansas Medicaid
Refunds
PO Box 8181
Little Rock, AR 72203
Provider Name
Provider ID Number/ Taxonomy Code
Refund Check Number
Refund Check Date
Refund Check Amount
Information needed on each claim being refunded
Claim 1
Claim 2
Claim 3
13-digit Claim Number (from RA)
Beneficiary’s ID Number (from RA)
Beneficiary’s Name (Last, First)
Date(s) of service on claim
Date of Medicaid payment
Date(s) of service being refunded
Services being refunded
Amount of refund
Amount of insurance received, if applicable
Insurance Co. name, address, and policy number, if applicable
Reason for return (see codes listed below)
1.
BILL:
A billing or keying error was made.
2.
DUP:
A payment was made by Arkansas Medicaid more than once for the same
service(s).
3.
INS:
A payment was received from a third party source other than Medicare.
4.
MC ADJ:
An over application of deductible or coinsurance by Medicare has
occurred.
5.
PNO:
A payment was made on a recipient who is not a client in this office.
6. OTHER: (Please explain)
Signature
Date
Telephone
HP-CR-002 (Rev. 4/07)
Instructions for Completing the Explanation of Check Refund Form:
Provide the following information in the appropriate fields on an
Explanation of Check Refund Form for each refund you send to Gainwell
Technologies:
1.
Provider’s name, provider ID number, and taxonomy code.
2.
Refund check number, check date and check amount
3.
13-digit claim number (from RA)
4.
Beneficiary’s ID number and name (as it appears on the RA)
5.
Dates of service on the claim
6.
Date of Medicaid payment
7.
Date of service being refunded
8.
Services being refunded (enter procedure and type of service code)
9.
Amount of refund
10.
Amount of insurance received
11.
Insurance name, address and policy number
12.
Reason for return (from codes listed on form)
13.
Signature, date and telephone
This information will allow the refund to be processed accurately and
efficiently.