Overpayment/Voucher Deduction Request
This form is to be used to request a deduction on a future remittance advice (voucher) in response to a recent recoupment request from Asuris, or as a result of an overpayment discovered by your internal claims review process. Please use the comment section for additional information.
Please note: If you have received a mailed refund request from Asuris it will automatically be deducted from a future voucher after the state required time frame has elapsed. If you would like the overpayment to be deducted immediately fill out and submit this form. If you have an Explanation of Benefits (EOB) or Other Party Liability etc., please use the PDF form to email or fax to us.
Asuris has our permission to automatically deduct the requested amount for the following claim(s):
*Asterisks indicate required fields.
Please complete all fields of this form to ensure your request is processed quickly and accurately.