Full Self-Disclosures are required for any non-claim-based Medicaid overpayment, and for Fee for Service (FFS) claim overpayments that are not appropriate for the Abbreviated Self-Disclosure Process. 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 Full Self-Disclosure Statement and Certification Form must be submitted to OMIG's Self-Disclosure Unit within sixty (60) days from the date the overpayment was identified. The Full Self-Disclosure Statement contains embedded links to the Claims Data Form and MPC Form, which are Excel spreadsheets used for reporting data as applicable to the specific overpayment.
How to self-disclose using the Full Self-Disclosure Process
Click on the form links below and save them to your computer. Once they are 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 upload your self-disclosure form and documents and include an optional message, and then send them securely to OMIG.
What You Need
- Full Self-Disclosure Statement Form
- Certification Form
- Claims Data Form
For self-disclosing overpaid Medicaid claims. This form is also available in the Statement Form as an embedded link. - Mixed Payer Calculation Form
For self-disclosing salary and benefits paid to an excluded or non-enrolled employee. This form is also available in the Statement Form as an embedded file.
Secure Submission Link
Submit your completed Full Self-Disclosure: Secure Submission Link