© 2020 Palmetto GBA, LLC
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Printed Date: 9/22/2015
JJ providers that would like to submit a voluntary refund should complete the form(s) available on the Palmetto GBA website at www.Palmettogba.com. Once the form is completed, please submit the form and your payment to Palmetto GBA. These forms and payments can be submitted using our preferred method, eServices. Or, hard copy forms can be submitted using the mailing address found on the bottom of each form. Palmetto GBA encourages providers to utilize eServices for many things including ADRs, voluntary refunds and Credit Balance Reports.
eServices is a free download and easy to use. Providers paying by eCheck can select an option through the eService portal indicating that the payment is not associated with a demand. This option can be found in the Financial Tools section and will ensure the payment is classified as a voluntary refund. Through eServices providers are able to attach an Excel spreadsheet with the claim detail, as well as the voluntary refund form. Providers needing to submit for multiple adjustments should include one form and an attached spreadsheet that contains each voluntary refund with all the pertinent information that is found on the form. If there are multiple claim adjustments associated with the voluntary refund, we encourage one check to cover all of the adjustments. This is for Medicare Secondary Payer (MSP and non-MSP).
Please note: this format is different from Cahaba’s instructions that providers may be familiar with.
Hard copy checks, forms, and encrypted CDs or thumb drives are still accepted.
However, eServices is faster, more efficient, and assures more accurate processing. Providers wanting to submit hard copy refunds need to ensure these requests, including Excel spreadsheets, are legible. Please note the mailing address at the bottom of the appropriate form if mailing in hard copy refunds. Providers that are requesting an adjustment and not submitting a check should submit the reopening form and not the voluntary refund form.
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Last Updated: 03/28/2019