CMS Pub. 100-04, ch. 30, § 100.10

1. Letter to Provider (Institutional Services).

2. Letter to Beneficiary Who Requests Indemnification (Institutional Services).

3. Letter to Someone Other Than Beneficiary Who Requests Indemnification.

4. Letter to Practitioner or Supplier (Noninstitutional Services)

5. Letter to Beneficiary Who Requests Indemnification (Noninstitutional Services)

6. Letter to Someone Other Than Beneficiary Who Requests Indemnification

(Noninstitutional Services)

7. Form SSA-795, Statement of Claimant or Other Person.

Exhibit 1 - Letter to Provider

(Rev. 1, 10-01-03)

To: Provider

Dear Administrator:

Under §1879 of the Social Security Act, a Medicare beneficiary is relieved of the liability

for certain noncovered services if the beneficiary did not know and could not reasonably

have been expected to know that the items or services were not covered. Further, the law

provides that the provider is liable if it is found that the provider knew or could

reasonably have been expected to know that the items or services were not covered by

Medicare.

On (date of limitation on liability notice), your facility was notified that the services

provided to (beneficiary’s name) during the period (_________) to (_________) were not

covered under Medicare and that you were liable for these items and services.

(Requester’s name) has submitted evidence that establishes that he paid your facility

(amount paid) for the services received by (beneficiary’s name). Because your facility

has collected payment from (requester’s name) after being determined liable for these

services, §1879(b) of the Act requires that the Medicare program make direct payment

(indemnification) to him for this amount, for which (beneficiary’s name) is responsible.

A check in the amount of (amount of check) is being sent to (requester’s name). This

indemnification payment represents an overpayment to your facility and it will be

withheld from future Medicare payments due you unless you advise this office that

refund of the incorrect amount(s) has been made to (requester’s name).

If you do not agree with the amount determined to have been paid you, please contact this

office in writing within 15 days of the date of this letter.

Sincerely yours,

Exhibit 2 - Letter to Beneficiary Who Requests Indemnification

(Rev. 1, 10-01-03)

Dear (Beneficiary’s Name):

Your request for refund of improper payment under §1879 of the Social Security Act (the

limitation on liability provision) for the noncovered services provided you at (name of

provider) from (date) to (date) has been received.

The evidence submitted establishes that, even though you were not responsible for the

services you received, you paid (provider’s name) (amount paid) for the services. Your

refund for these payments to (name of provider) has been calculated to be

(indemnification amount). This figure represents full repayment for the charges you paid.

Your Medicare utilization record will not be charged where noncovered services were

provided to you and you were determined not liable.

If you have any questions concerning the matters discussed in this letter or the amount of

the check enclosed, please call this office. If you prefer to visit your local social security

office, please take this letter with you.

Sincerely yours,

Exhibit 3 - Letter to Someone Other Than Beneficiary Who Requests

Indemnification

(Rev. 1, 10-01-03)

Dear (Person’s Name):

Your request for refund of improper payment under Section 1879 of the Social Security

Act (limitation of liability provision) for the noncovered services provided (beneficiary’s

name) at (name of provider) from (date) to (date) has been received.

It was determined that (beneficiary’s name) was not liable for the services. The evidence

you submitted establishes that you paid (provider) (amount paid) for the services

provided (beneficiary’s name). Your refund has been calculated to be (indemnification

amount). This figure represents full repayment based on the expenses incurred by

(beneficiary’s name) in the amount of $(amount).

If you have any questions concerning the matters discussed in this letter or the amount of

the check enclosed, please call this office. If you prefer, you may visit the local social

security office. If you do, take this letter with you.

Sincerely yours,

Exhibit 4 - Letter to Practitioner or Supplier (Noninstitutional Services)

(Rev. 1186, Issued: 02-23-07; Effective: 01-01-06; Implementation: 05-23-07)

Dear ____________________:

Under §1879 of the Social Security Act, a Medicare beneficiary is relieved of the liability

for certain categories of noncovered items or services submitted as assigned claims if the

beneficiary did not know and could not reasonably be expected to know that the items or

services would not be covered. Further, the law provides that the practitioner or supplier

will be liable for the charges if it is found that he/she knew or could reasonably be

expected to know that Medicare would not cover the items or services.

On (date of limitation on liability notification), you were notified that the following items

or services provided to (name of beneficiary) were not covered and that you were liable

for the charges for these items or services:

Description of Services Date Provided

(Beneficiary or other person on behalf of beneficiary) has submitted evidence which

establishes that he/she paid you $______ for the items or services described above. Since

it has been determined that you are liable for the items or services, §1879(b) of the Act

requires that the Medicare program make payment (indemnification) to him/her for this

amount. The amount of this payment will be treated as an overpayment to you and

appropriate collection action will be taken unless you advise this office that refund has

been made to (name of requester).

If you do not agree with the amount that (name of requester(s)) has established he/she

paid you, please notify this office.

If we do not hear from you regarding the amount of the payment or that you will make

refund directly by_____________ (15 days after date of this notice) payment will be

made to (name of requester(s)) and action will be taken to collect the overpayment from

you.

If you disagree with this determination, you may request a redetermination. The bases for

such a request are: (1) that the services you provided were reasonable and necessary; (2)

that you did not know, and could not reasonably have been expected to know, that

Medicare would not pay for the services; or (3) that you notified the beneficiary in

writing, before the services were furnished, that Medicare likely would not pay for the

services. The request for redetermination must be in writing, and it must be filed within

120 days of the date you received the initial determination. If you have already received

an adverse redetermination, you may request a reconsideration within 180 days of the

date you received the redetermination. Our office will assist you if you need help in

requesting a redetermination or a reconsideration. You need not file another request for a

redetermination or a reconsideration if you already have taken such action.

Exhibit 5 - Letter to Beneficiary Who Requests Indemnification

(Noninstitutional Services)

(Rev. 1186, Issued: 02-23-07; Effective: 01-01-06; Implementation: 05-23-07)

Dear (Beneficiary’s name):

Your request for indemnification (i.e., refund of improper payment) under §1879 of the

Social Security Act (the limitation on liability provision) for the noncovered services

provided you by (physician’s/supplier’s name) on (date) has been received.

The evidence submitted establishes that you paid (physician/supplier) (amount paid) for

the noncovered services. It was determined upon redetermination that you were not liable

for these charges. Your refund for these payments to (physician/supplier) has been

calculated to be (indemnification amount). This figure represents full repayment for the

charges you paid.

If your (physician/supplier) requests an appeal of this claim, it is possible that Medicare

might find that your (physician/supplier) also did not know that Medicare would not pay

for this service, or that this service should not have been denied. In that case, Medicare

would pay your (physician/supplier) for this service. Also, you would be responsible for

any deductible and coinsurance amounts. If this happens, you will receive a copy of the

notice to your (physician/supplier).

Any future items or services of this type provided to you will be your responsibility

because this is your notice that Medicare does not cover these services.

If you have further questions concerning this matter, please call this office. If you prefer

to visit your social security office, please take this letter with you.

Exhibit 6 - Letter to Someone Other Than Beneficiary Who Requests

Indemnification (Noninstitutional Services)

(Rev. 1186, Issued: 02-23-07; Effective: 01-01-06; Implementation: 05-23-07)

Dear (Person’s name):

Your request for indemnification (i.e., refund of improper payment) under §1879 of the

Social Security Act (limitation on liability provision) for the noncovered services

provided (beneficiary’s name) by (name of physician/supplier) on (date) has been

received.

It was determined upon redetermination that (beneficiary’s name) was not liable for the

charges.

The evidence establishes that you paid (physician/supplier) (amount paid) for the services

provided (beneficiary’s name). Your refund has been calculated to be (indemnification

amount). This figure represents full repayment for the expenses incurred by

(beneficiary’s name).

If his/her (physician/supplier) requests an appeal of this claim, it is possible that Medicare

might find that the (physician/supplier) also did not know that Medicare would not pay

for this service, or that this service should not have been denied. In that case, Medicare

would pay the (physician/supplier) for this service. Also, (beneficiary’s name) would be

responsible for any deductible and coinsurance amounts. If this happens, (beneficiary’s

name) will receive a copy of the notice to his/her (physician/supplier).

Any future items or services of this type provided to (beneficiary’s name) will be his/her

responsibility because this is your notice that Medicare does not cover these services.

If you have further questions concerning the matters discussed in this letter or the amount

of the check enclosed, please call this office. If you prefer to visit the social security

office, please take this letter with you.

Exhibit 7 - Statement of Claimant or Other Person

(Rev. 1, 10-01-03)

Link to an exhibit of the Form SSA-795, “Statement of Claimant or Other Person,” at:

http://www.ssa.gov/online/ssa-795.pdf.