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The form is optional and is not used for corrected claims; corrected claims require a Corrected Claim Cover Sheet and documentation. Providers select a handling option: attach a check, request a voucher deduction/offset, or request a refund request letter for amounts of $25 or more, with documentation requirements and processing guidelines.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/overpayment-notification-form-general-instructions-for-providers/278161/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/overpayment-notification-form-general-instructions-for-providers/278161.png","ImageObject",442,249,{"name":88,"@type":89},"Aria Callaghan","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-27","2026-09-15",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",19,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Can providers use the Overpayment Notification Form for corrected claims?","Question",{"text":109,"@type":110},"No. Corrected claims require the Corrected Claim Cover Sheet and any required documentation, not the Overpayment Notification Form.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How should a provider handle an overpayment under $25?",{"text":114,"@type":110},"Providers are not requested to submit refunds or voucher deductions for amounts under $25, but they may be submitted voluntarily. For documentation needs, use the Standard Provider Letter For Refunds Less Than $25.",{"name":116,"@type":107,"acceptedAnswer":117},"What happens if the overpayment of $25 or more is not refunded within 60 days?",{"text":118,"@type":110},"If the total overpayment amount is not refunded within 60 days from the initial notice, the amount will be offset against future payments.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},278161,1790000609,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},962084926284,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","OVERPAYMENT NOTIFICATION FORM – GENERAL INSTRUCTIONS FOR PROVIDERS  \nThis form is for use by providers when an overpayment is being returned and/or action is being requested by LifeWise Health Plan of Washington. Following the guidelines below will expedite the handling of your overpayment. The use of this form is optional.  \nDo not use this form for corrected claims. If you need to submit a corrected claim, please complete the Corrected Claim Cover Sheet and submit it along with any required documentation. If your corrected claim results in an overpayment in an amount of $25 or more, we will send you a refund request letter for the overpayment amount.  \nFollow these steps for the completion and submission of the Overpayment Notification Form:  \n1. Mark the appropriate box on the form to indicate how you would like LifeWise to handle your overpayment. Your options include:  \na. Check attached: Please submit a check along with the completed Overpayment Notification Form and mail them to  \nLWWA Provider Refunds  \nPO Box 840542  \nLos Angeles, CA 90084-0542  \nb. Request a voucher deduction/offset: You will receive a letter from Calypso Healthcare Solutions, an independent company responsible for providing subrogation services to LifeWise Health Plan of Washington, notifying you that the voucher deduction process has been initiated. The overpayment amount will be offset against future payments (voucher deducted).  \nc. Please send a refund request letter: You will receive an Overpayment Refund Request letter for refunds of $25 or more. Once you receive the initial letter, you can send in your payment. Please attach your payment to the refund request letter to expedite processing. Important note: If the total overpayment amount has not been refunded within 60 days from your initial notice, the amount will be offset against future payments.  \n2. Attach any required documentation.  \nGuidelines to support prompt processing of your request:  \n• We will not send you a refund request letter for refunds less than $25. If you need documentation for your office, please use our Standard Provider Letter For Refunds Less Than $25.  \n• There is no need to submit a duplicate notification to us via fax if you are mailing a check to us.  \n• An Explanation of Benefits (EOB) from the other insurance carrier is required if coordination of benefits is the reason for overpayment.  \nOverpayment Notification Form  \nUse this form when notifying LifeWise Health Plan of Washington of an overpayment.  \nAll areas with an asterisk (*) must be filled out.  \n Check attached  \n Check this box to request a voucher deduction/offset  \n Please send a refund request letter (Note: If the total overpayment amount has not paymenten refunded within 60 days from your initial notice, the amount will be offset against future  \n| Claim/Patient Information |  |  |\n| --- | --- | --- |\n| * Provider Name   Subscriber Name  \u003Cbr>*Subscriber Number  \u003Cbr>Include plan prefix\u003Cbr>*Date of Service   | *Claim Number\u003Cbr>* Patient Name\u003Cbr>Patient DOB\u003Cbr>*Claim Total Charge | Complete if different from subscriber $ |\n| Overpayment Amount  $ \u003Cbr>Please note that we do not request refunds or voucher deduct for overpayments under $25. These can be submitted voluntarily. * |  |  |\n\nWho should we call if we have a question?  \n*Contact Name:    \n*Contact Number:    \nProvider’s Mailing Address  \nAttention:    \n*Provider Group  \nName:    \n*Address:    \n*City, State ZIP:    \nQuestions: Call Calypso at 800-364-2991  \nPlease fax this form to 425-918-4722 Thankyou!  \n* Reason for Overpayment  \n Primary Insurance Information (Coordination of Benefits)  Required: EOB from other insurance plan  \nName of other insurance:   Insurance Address (include ZIP code):   Subscriber name:   Phone \\#:  ( )    Policy \\# :   Group \\#:    \n Duplicate payment/other claim number is:    Incorrect patient:    Services not rendered:    Subrogation:    Other:  \n*We reserve the right to request a refund of multiple claims that in","cbCaifGJbmE4oTnZ","https://ap.wps.com/l/cbCaifGJbmE4oTnZ","pdf",176265,"English","# Overpayment Notification Form - General Instructions for Providers\n## Completion and Submission Steps\n## Handling Options for Overpayments\n## Documentation and Processing Guidelines\n## Overpayment Notification Form Fields and Contact Information","[{\"question\":\"Can providers use the Overpayment Notification Form for corrected claims?\",\"answer\":\"No. Corrected claims require the Corrected Claim Cover Sheet and any required documentation, not the Overpayment Notification Form.\"},{\"question\":\"How should a provider handle an overpayment under $25?\",\"answer\":\"Providers are not requested to submit refunds or voucher deductions for amounts under $25, but they may be submitted voluntarily. For documentation needs, use the Standard Provider Letter For Refunds Less Than $25.\"},{\"question\":\"What happens if the overpayment of $25 or more is not refunded within 60 days?\",\"answer\":\"If the total overpayment amount is not refunded within 60 days from the initial notice, the amount will be offset against future payments.\"}]","OVERPAYMENT NOTIFICATION FORM - GENERAL INSTRUCTIONS FOR PROVIDERS | PDF",1789507537]