Provider Self-Audit

PA Health and Wellness encourages providers to voluntarily come forward and disclose overpayments or improper payments of Medicaid (or Medical Assistance (MA)) funds within 60 calendar days after the date on which the overpayment was identified. While providers are required to promptly return inappropriate payments that they have received from PA Health and Wellness or the MA Program, the use of the Provider Self-Audit Protocol is voluntary. The protocol simply provides guidance to providers on the preferred methodology to return inappropriate payments. Providers should return any payments identified through this protocol directly to PA Health and Wellness if applicable but must also make the self-disclosure directly to DHS. Details on the DHS Self-Audit Protocol may be found on the DHS Website.

Provider Name: *

Provider TIN(s): *

Provider NPI(s): *

Your Name: *

Job Title: *

Phone Number: *

Email: *

Date of audit completion: *

Time period covered by the review/dates of service: *

Explain why this timeframe was selected: *

Total dollar amount impacted: *

Total dollar amount impacted is estimated OR projected: Estimated Projected

Was a refund check already sent?: Yes No

If the refund check was already sent, provide the date and amount:

Overview of Issues Identified: *

Describe corrective actions to be or already taken to assure errors do not reoccur in the future: *

To the extent that payments can be returned through the claim adjustment process, the provider should follow the claim adjustment instructions in the located in the Provider Manual. Otherwise, providers should send refund checks made payable to “PA Health & Wellness" at the following address:

PA Health & Wellness
P.O. Box 3765
Carol Stream, IL 60132-3765

*Refund checks should be accompanied by the list of the impacted claim(s).