Sample Suspension Warning Letter

10.3.1 - Sample Suspension Warning Letter (Rev. 99, Issued: 06-30-06; Effective/Implementation Dates: 10-02-06) This is a sample suspension warning letter, which the FIs may use to notify the provider. (Optional) Exhibit 1 - Sample Suspension Warning Letter Date: [Name], [Job Title] [Company Name], [Provider Number] [Address] [City], [State] [Zip] RE: Past Due Quarterly Credit Balance Report Suspension Warning Letter Quarter Ended: _____________ Dear [Title] [Last Name]: The Medicare Credit Balance Report, CMS-838, for the quarter ending______________ was due on ______________________. Our records show the Medicare Credit Balance Report for the quarter is overdue. Since we have not received your report, this letter is notification that, fifteen (15) days from the above date of this correspondence, Medicare will implement a 100% withholding of your payments until the Credit Balance Report is received. If you have any questions regarding this matter, please contact ____________ at (___) _________. Sincerely, [Name] [Title]