Refund 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 Regence, 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 Regence 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.

Regence 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.
Your details:
*
 Member ID:
 
*
 Claim number(s) :
 
*

Comments:

 

In the comment section:

  • Indicate the amount to be deducted
  • Indicate if this is in response to a recoupment request from Regence, or
  • If the result of your own overpayment discovery, indicate if the error was:
    • Not our patient
    • Duplicate payment
    • Other insurance primary
    • Third party responsiblity (please explain)
    • Other (please explain)
* Office name:
* Tax ID and/or Rider Number:
* Office contact name:
* Email:
* Phone:
     
Reason for deduction(s):
  Response to recoupment request
  Duplicate payment
  Late credit
  Cancelled charge
  Third party payment
  Other (please specify)
   
         

Submission of this form serves as notification on how to proceed with your deduction request and/or Regence's recent recoupment request. Any claim(s) processed as a result of this request will be reflected in a future remittance advice.

The proposed overpayment amount is based on the current claim status within our system and any adjustments could affect patient responsibility, which may include copayment, deductible amounts and coinsurance amounts.