Please download the form, complete each field and print. Include the form with your refund so we can properly apply the refund and record the receipt.If we have identified an overpayment and request a refund, please mail the check along with a copy of the overpayment request letter we sent you. This webpage defines the two situations in which overpayment occurs MSP (Medicare Secondary Payer) Overpayments and Non MSP Overpayments. Providers should attach documentation substantiating the overpayment, such as an EOB, if the overpayment was due to payment received from a third party payer. We have identified the following overpayment and are in good faith voluntarily refunding all monies collected in error. In the event that you have received overpayment, please return the funds to Cigna HealthcareSM at: Cigna Healthcare P O Box 188012 In order for an overpayment refund to be processed in a timely manner, please submit a completed form with all refund checks and supporting documentation.

Overpayment Letter To Insurance Company In Arizona

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