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Claim Recoupment Formulaic Correction/Adjustment Footnote: Dollars recouped or status adjustments for this claim will be reflected on a future Explanation of Payment. Use only one form per claim.
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What is Claim Recoupment Claim Correction/Adjustment Form?

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The claim recoupment form claim is a form used to request the recovery of funds previously paid out.
Any individual or organization seeking to recoup funds is required to file a claim recoupment form claim.
The claim recoupment form claim must be filled out with accurate and detailed information regarding the funds being requested for recoupment.
The purpose of claim recoupment form claim is to recover funds that were mistakenly paid out or are owed to the filer.
The claim recoupment form claim must include details on the amount of funds being requested for recoupment, the reason for the request, and any supporting documentation.
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