Abbreviated Self-Disclosures are appropriate for reporting and explaining Fee for Service (FFS) claim overpayments that were received due to routine or transactional types of errors, and that have been voided or adjusted to repay Medicaid. These types of repayments are also sometimes referred to as administrative billing adjustments or voids. Please see Self-Disclosure Guidance for information on how to determine the appropriate Self-Disclosure Process for your overpayment.
To meet the obligation of reporting, returning, and explaining a completed Abbreviated Statement Form must be submitted to OMIG's Bureau of Self-Disclosure using the Secure Submission Link below within sixty (60) days from the date that the overpayment was identified.
As a best practice for efficiency, OMIG recommends that Providers save the Abbreviated Statement Form and use it to document voided or adjusted claims appropriate for self-disclosure through the Abbreviated Self-Disclosure Process as they are identified and voided or adjusted. To submit, use the Secure Submission Link below.
Abbreviated Self-Disclosures can be submitted as claims are identified. Providers can also document voided or adjusted claims on the form and submit it once a month for the FFS claims that have been identified and repaid in the previous month. Either process is acceptable and will ensure that the Provider meets the sixty (60) day requirement.
NOTE: Voiding or adjusting overpaid FFS claims does repay Medicaid, but it does not satisfy the obligation to report and explain the overpayment.
How to Self-Disclose using the Abbreviated Self-Disclosure Process
Click on the Abbreviated Statement form link below and save the spreadsheet to your computer. This is the only form accepted by OMIG for submission of an Abbreviated Self-Disclosure. Additionally, forms may not be password protected or sent with additional encryption. The use of any other form, a submission with additional encryption, or a password protected form, will cause the submission to be rejected.
Once the form is complete, navigate back to this page and use the Secure Submission Link below to submit them to OMIG’s Self-Disclosure Program. The Secure Submission Link will bring you to a page where you can enter your contact information, upload the completed Abbreviated Statement Form spreadsheet, and send them securely to OMIG.
Please note that the Secure Submission Link will protect the data submitted, no additional encryption is required. Additionally, the Secure Submission Link below is the only avenue for successful submission of an Abbreviated Self-Disclosure.
What You Need
• Abbreviated Self-Disclosure Statement Form (this form is required)
Secure Submission Link
Submit your Abbreviated Self-Disclosure at: Secure Submission Link
(this is the only acceptable format for submission)