A self-disclosure submission requires completion of a Self-Disclosure Form and a Claims Data File of affected Medicaid claims. Note, the Claims Data File is embedded in the Self-Disclosure Form.
Claims should include the following:
___Claim Reference Number (CRN) or Transaction Control Number (TCN), a 16-digit number
___Provider’s Medicaid MMIS ID and/or NPI number
___Medicaid group ID number (applicable if only submitted on claim)
___Medicaid recipient’s first name
___Medicaid recipient’s last name
___Medicaid recipient’s CIN, an 8-character number (e.g., AA#####A)
___Date of service (not the date billed)
___Incorrect rate or procedure codes, if applicable
___Correct rate or procedure codes
___Amount that should have been paid, if applicable
___Amount paid by Medicare or any other third party, if applicable
NOTE: Do not include a check for overpayment. Do not void or adjust the claims after they are submitted for review.
After OMIG’s review of all disclosure submission material, you will receive a final letter indicating the overpayment dollar amount and the procedure for submitting the payment. If the submitted claim data does not materially match OMIG’s payment data, you will be contacted before a final letter is issued.
For questions or additional information, send an e-mail to [email protected] or call 518-402-7030.