Sample Letter to Beneficiary Where Recovery Is Sought From Provider

90.4 - Sample Letter to Beneficiary Where Recovery Is Sought From Provider (Rev. 70, Issued: 05-27-05; Effective and Implementation dates: 06-27-05) A notice to the beneficiary is required whenever a provider is requested to repay Medicare because of an overpayment determined as a result of services provided to the beneficiary. If a MSN is generated the appropriate notice codes shall be utilized informing the beneficiary that the provider may be requested to repay Medicare. If this occurs no further action needs to be taken. However, if a MSN is not generated notice shall be sent to the beneficiary. Below is a sample letter to a beneficiary where recovery is sought from the provider. Dear ________________: In (month and year), we made a payment to (provider or physician name and location) on your behalf for services provided to you (insert dates). We have reviewed the payment and determined that the services were not covered under the Medicare program. (The Contractor shall explain as clearly as possible the reason why all, or part, of the payment was erroneous.) It shall use either paragraphs A, B or C below as appropriate: A - Provider Liable for Medically Unnecessary or Custodial Care Services (Physician Liable for Medically Unnecessary Services) (See Medicare Claims Processing, Chapter 30, Financial Liability Protections.) We have found that you (the beneficiary) did not know or have any way of knowing that the services you (he/she) received during (dates of services for which beneficiary's liability has been waived) would not be considered to be reasonable and necessary by Medicare. However, the records show that (physician’s name) should have known that such services would be considered noncovered. When this situation occurs, the law requires that the liability for these noncovered services be transferred to the physician. Therefore, you (the beneficiary) are (is) not responsible for the charges billed by (provider's name) except for any charges for services or items never covered by Medicare. If you (the beneficiary) have (has) paid (provider's name) for these services, you may be entitled to a refund. To obtain this refund, please advise this office and enclose the following documents: • A copy of this notice; • The bill you received for the services; and • The payment receipt from (provider's name), your cancelled check, or any other evidence showing that you (the beneficiary) have (has) already paid (provider's name) for the services at issue. You should file your written request for payment within 6 months of the date of this notice. B. Provider at Fault and Beneficiary Not at Fault for Medically Unnecessary or Custodial Services and the Overpayment was Discovered Subsequent to the Third Calendar Year After Year Payment Was Approved (Provider's name) has been requested to refund this overpayment. Under the Medicare law, (provider's name) is prohibited from billing you, or any other source, for these noncovered services. If (provider's name) sends you a bill for these services, send it to us with a copy of this letter. C. All Other Cases (Provider's name) has been requested to refund the overpayment. Since the above services are not covered by Medicare, (Provider's name) may ask you to pay for them. However, if you are billed, this is a matter between you and (Provider's name) and will not affect your entitlement to future Medicare benefits in any way. NOTE: The notification of appeal rights should be in accordance with the reopening rules in Medicare Claims Processing, Chapter 29, Appeals of Claims Decisions.