Optional Paragraphs for Inclusion in Demand Letters

110.6 - Optional Paragraphs for Inclusion in Demand Letters (Rev. 13183; Issued: 04-24-25; Effective: 05-27-25; Implementation: 05-27-25) The contractor should use or adapt the following paragraphs in explaining how the overpayment occurred. A. Inpatient Hospital Deductible or Coinsurance Not Properly Assessed – Part A 1. General – Part A “Medicare pays all costs of covered services furnished during the first 60 days of hospitalization except for the first $_____ (the inpatient deductible). For the 61st through the 90th days Medicare pays all costs except for a coinsurance of $_____ per day. After 90 days of benefits have been used, an additional 60 lifetime reserve days are available. There is $_____ per day coinsurance for each lifetime reserve day used. 2. Deductible Overpayment “Our records show that the claim for the inpatient services you received at (provider's name) was improperly processed. Benefits were mistakenly paid for ____ days in full. However, since these were the first inpatient hospital services furnished in this benefit period you are responsible for the deductible and the $_____ inpatient hospital deductible should have been subtracted from the reimbursement paid (provider's name) on your behalf. Thus (provider's name) was overpaid by $______.” 3. Coinsurance Overpayment “Our records show that the claim for the inpatient services you received at (provider's name and address) was improperly processed. Benefits were mistakenly paid for ____ full days (less the $____ deductible). However, since you had previously been hospitalized for ____ days at (name of provider where previously hospitalized) during that benefit period, your claim should have been processed as ___ full days and ____ coinsurance days (and/or lifetime reserve days). Therefore (provider's name) has been overpaid on your behalf for _____ coinsurance days at $_____ per day and/or lifetime reserve days at $______ per day) (less $_____ for the inpatient hospital deductible which was improperly applied to your claim). The total overpayment is $__________.” B. Deductible Not Properly Assessed -Part B “Under Part B of Medicare, no reimbursement may be made for the first $100 of approved charges incurred by a beneficiary in each calendar year.” (If pertinent, add: “This is true even if you were covered under Medicare for only part of the year.”) In these cases, explain the computation of the overpayment. C. Payment Made Under Workers’ Compensation Law We paid $_____________ in benefits for services furnished you by (provider's, physician’s or supplier’s name and location) on (dates). However, these payments were in error since these services were covered under the (State) workers' compensation law and Medicare may not pay for services that are covered under workers' compensation. Since (provider's, physician’s, supplier’s name) was not at fault in causing this overpayment, you are required to refund the $_______________ Medicare paid on your behalf. You may wish to submit the bill for these services to your employer or his workers' compensation carrier for payment under the State workers' compensation provisions.” D. Beneficiary Not Entitled to Medicare Benefits "The Social Security Administration's records show that you were not entitled to (specify Part A hospital insurance and/or Part B medical insurance) benefits when these services (item(s)) were furnished. Your Medicare Handbook explains the difference between Part A (hospital) and Part B (medical) insurance. The decision that you were not entitled to these benefits was made by the Social Security Administration, and not by (contractor name). Therefore, if you disagree with this decision, or if you have any questions about your entitlement to Medicare benefits, contact your Social Security office. If you go to the Social Security office, take this letter with you.”