Sample Demand Letter for Claims Accounts Receivables

40.2- Sample Demand Letter for Claims Accounts Receivables (Rev. 41, 04-30-04) Below is a sample demand letter that FIs may use when demanding Claims Accounts Receivables. The Extended Repayment Plan enclosure can be found at Chapter 4, §20, Exhibit 2. Date Certified Mail Name/Address Re: Provider Number Claims Accounts Receivable Dear _____: On ____________, a claim adjustment was entered in our system under provider _____ for $___________. Since then, adjustments were made to the claim and a balance in the amount of $______________ has been outstanding for 60 days. As this amount has not been recouped through claims submission, the purpose of our letter is to request that this amount be repaid to our office. For your reference, a copy of the Claims Accounts Receivable Transaction Summary is enclosed. (Insert the name of the detailed summary report enclosed. This report should include sufficient information needed by the provider to identify the overpayment). Submit your check payable to ______________, to the following address: In order to ensure that your check is credited to this overpayment, please enclose a copy of this letter with your payment. Until payment in full is received or an acceptable extended repayment request is received all payments due to you are being withheld. (This includes claims, settlement amounts, or interim payments.) If you have reason to believe that withhold should cease you must notify our office before __________ and provide documentation as to why this withholding action should not continue. We will review your documentation, but will not delay recoupment during the review process. This is not an appeal of the overpayment determination. In addition, in accordance with 42 C.F.R. §405.378, simple interest at the rate of ____% will be charged on the unpaid balance of the overpayment, beginning on the 31st day. Interest is calculated in 30-day periods and is assessed for each full 30-day period that payment is not made on time. Thus, if payment is received 31 days from the date of this letter, one 30-day period of interest will be charged. Each payment will be applied first to accrued interest and the remaining amount to principal. Additional interest of $___ will be assessed against the principal balance on ____ and will continue to assess at the rate of ___% a year for each 30-day period the principal amount remains unpaid. In addition, please note that Medicare rules require that payment be either received in our office by ___ or United States Postal Service postmarked by that date in order for the payment to be considered timely. A metered mail postmark received in our office after ___ will cause an additional month’s interest to be assessed on the debt. We request that you refund this amount in full. If you are unable to make refund of the entire amount at this time, please advise our office immediately so that we may determine if you are eligible for a repayment schedule (See enclosure for details). Any repayment schedule (where one is approved) would run from the date of this letter. If we do not hear from you, your interim payments will continue to be withheld and applied towards the outstanding overpayment balance. Any amount withheld will not be refunded. If you feel you have reason to appeal this adjustment, please refer to the original remittance advice dated _______ for additional instruction. If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding, Medicare financial obligations will be resolved in accordance with the applicable bankruptcy process. Accordingly, we request that you immediately notify us about this bankruptcy so that we may coordinate with both the Centers for Medicare & Medicaid Services and the Department of Justice so as to assure that we handle your situation properly. If possible, when notifying us about the bankruptcy, please include the name the bankruptcy was filed under and the district where the bankruptcy is filed. If you have a question regarding why these adjustments were made, please contact our ___________at ________. If we can assist you further in the resolution of this matter, we will be glad to do so. We look forward to hearing from you shortly. Sincerely, (name and title)