CMS Pub. 100-04, ch. 30, § 140.6.1

Notice 1 - Full Denial

If the doctor should have known that Medicare would not pay for the

denied services and did not tell you in writing before providing the

services, you may be entitled to a refund of any amounts you paid.

However, if the doctor requests an appeal of this claim within 30 days, a

refund is not required until we complete our appeal. If you paid for this

service and do not hear anything about a refund within the next 30 days,

contact your doctor’s office.

Notice 2 - Reduction in Payment

If the doctor should have known that Medicare would not pay for the more

extensive service and did not tell you this in writing before providing the

service, you may be entitled to a refund of any amount you paid which is

more than the doctor is allowed by law to charge under Medicare for the

less extensive service. However, if the doctor requests an appeal of this

claim within 30 days, a refund is not required until we complete our

appeal. If you paid for the more extensive service and do not hear anything

about a refund within the next 30 days, contact your doctor’s office.

In addition, add the following paragraph:

You could have avoided paying $_______, the difference between the maximum

amount the doctor or supplier is allowed to charge and the amount Medicare

approved for the lesser service, if the claim had been assigned.