Sample Notification/Rejection Letter

10.4.1 - Sample Notification/Rejection Letter (Rev. 99, Issued: 06-30-06; Effective/Implementation Dates: 10-02-06) This is a sample notification letter, which FIs may use to notify the provider. (Optional) Exhibit 2 – Notification/Rejection Letter Date: [Name], [Job] [Company Name], [Provider Number] [Address] [City], [State], [Zip] RE: Notification/Rejection Letter Quarter Ended: ___________ Dear [Title], [Last Name]: During our review of your submitted Medicare Credit Balance Report (CMS-838) Detail Page for the quarter ending________________, we noted that __________ was not included with your report. In accordance with published Centers for Medicare and Medicaid Services (CMS) manual instructions, your office must include an adjustment bill for each reported credit balance listed in column 9 of the Detail Page. You should refer to your Provider Instructions for a detailed description of the published guidelines, or visit us on our Web site, www.__________.com. We must receive $________ for your payment of reported credit balances within fifteen (15) days from the date of this letter. If we do not receive a check and/or hard copy adjustment bills (UB-92 claim form) or electronic adjustment bills for these balances within 15 days from the date of this letter, your facility will be placed on one-hundred percent (100%) withhold up to the total amount owed to recoup the above liability on day 16. Make sure to include your Medicare Provider Number on your check. Your check should be mailed to the following address: _________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ If you have any questions related to this letter, please call me at (999) 123-4567. Sincerely, [Name] [Title]