Self-Disclosure Submission Checklist

NYS Office of Medicaid Inspector General (OMIG) Self-Disclosure Submission Checklist

A self-disclosure submission requires both a submission letter and claims data file of impacted Medicaid claims.

Submission Letter

Complete description of the circumstances surrounding the disclosure including:

___Provider’s name

___Provider’s Medicaid MMIS ID and/or NPI number

___Description of the error that occurred

___How the error was found

___Amount of Medicaid overpayment

___Dates of service (DOS) the claims error encompasses

___Actions taken to stop the error and prevent recurrence

___Names of personnel involved in the error, those who discovered the problem, and those involved in rectifying the problem

___Provider’s contact person’s name, phone number, and both mailing and e-mail addresses

___If the claims at issue have been voided, please note this in your disclosure letter

Claims Data File

Claims should be submitted in an Excel workbook either on a CD or electronic file and 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 paid

___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 over-payment. Do not void the claims after they are submitted for review.

If the submitted claim data does not match OMIG’s payment data, you will be contacted before a final letter is issued.

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.

All self-disclosure correspondence and claim files should be sent to:

NYS Office of Medicaid Inspector General Self-Disclosure Unit 800 North Pearl Street Albany, New York 12204-1822

or by secure e-mail to: This email address is being protected from spambots. You need JavaScript enabled to view it.

For questions or additional information, send an e-mail to This email address is being protected from spambots. You need JavaScript enabled to view it. or call 518-402-7030.

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