Immediate Recoupment Request Form - Electronic/E-mail
Complete this online form to initiate a request for immediate recoupment of an existing overpayment. All fields are required and the form must be completed in its entirety prior to submitting your request.
Note: Durable medical equipment (DME) suppliers should enter the document control number (DCN) indicated on your overpayment demand letter in the AR number field below.
Attention: Due to protected health information (PHI) Internet security policy requirements, we are unable to accept the following information:
- Medicare numbers
- Social Security Numbers
- Personal/beneficiary Medical information
- Confidential information