CMS Pub. 100-06, ch. 3, § 110.5

The contractor may use or adapt the following model letter for requesting refunds of

overpayments from beneficiaries:

"Dear Mr. ________:

A. Opening Paragraph:

"In (month and year) we paid (provider's, physician’s, supplier’s name and location) (you)

$___________ more than was due for services furnished by ____________ on _________ (from

__________ through __________) (on __________). We have reviewed the payment and determined

that it was incorrect. The correct payment should have been $________________."

The contractor shall include a clear and complete explanation of how the overpayment arose and how it

was calculated.)

It shall add if applicable: "We have recovered $________________ from (specify source). Thus, the

total remaining overpayment is $_______________.

B. Liability of Beneficiary When Payment Made to Physician or Supplier

If payment was made to the physician, add the following:

"Under the Medicare law, you are responsible for overpayments made on your behalf if the provider of

services was not at fault in causing the overpayment. In this case, (provider's, physician’s, supplier’s

name) was not at fault. Therefore, you are liable for the $_____________ incorrectly paid for the

services you received."

C. Request for Refund

"Please send us a check or money order for $ _________________, within 30 days. Make the check or

money order payable to (contractor name), and mail it in the enclosed self-addressed envelope.”

D. Possible Offset

“If other Medicare benefits become payable to you and you have not refunded the incorrect payment, we

will withhold the amount you owe from those benefits.” (In the initial letter the contractor shall add:

“beginning 60 days from the date of this letter.”)

E. Possible Referral to Social Security Administration

If the overpayment is over $1000, add the following:

“If you do not repay this amount, this overpayment may be referred to the Social Security

Administration (or Railroad Retirement Board) for further recovery action that, among other actions,

may result in the overpayment being deducted from any monthly social security (or railroad retirement)

benefits to which you may be entitled.”

F. Installment Payments

"If you are unable to refund this amount in one payment, you may make regular installments. To refund

in installments, you are required to pay a minimum of $_____________each month for ___ months.

However, we urge you to pay more each month so that this matter can be settled as soon as possible. If

you prefer to repay this overpayment through installments, please notify us promptly how much you are

able to pay and how often."

G. Possible Recovery from Other Insurance

(The contractor shall not use this paragraph where it has determined that the private insurer will not

pay.)

"If you carry private health insurance to supplement your Medicare benefits, you may be able to recover

the amount of this overpayment by claiming benefits from the other plan, or (name of provider or

physician) may be able to submit such a claim on your behalf. If you plan to file a claim with a

supplemental plan and use the proceeds to refund this overpayment, please let us know. If you need

help in filing such a claim, please contact any Social Security office."

H. Notification of Appeal Rights

The notification of appeal rights must be in accordance with the reopening rules in Medicare Claims

Processing, Chapter 29 – Appeals of Claims Decisions.

NOTE: If the overpayment was for medically unnecessary services or for custodial care, The contractor

shall begin the first sentence of the appeals paragraph:

"If you believe that this determination is not correct, or if you did not know that Medicare does not pay

for these services."

I. Notification of Waiver of Recovery Provision

"The law requires that you must repay an overpayment of Medicare benefits unless you meet both of the

following conditions:

• You were without fault in causing the overpayment in that the information you furnished

in connection with the claim was correct and complete to the best of your knowledge, and you had a

reasonable basis for believing that the payment was correct, and

• Paying back the overpayment would keep you from meeting your ordinary and necessary

living expenses or would be unfair.

If you claim that repayment will cause you serious financial hardship, it will be necessary to submit a

statement to the Social Security Administration regarding your income, assets, and expenses.

If you believe that both conditions for waiver of this overpayment apply in your case, please let us

know, giving a brief statement of your reasons. You may contact your Social Security office. You will

be notified if recovery of this overpayment is waived. If waiver cannot be granted, you will have the

opportunity to present your case at a personal conference. The conference will be conducted by an

employee of the Social Security Administration who did not participate in the initial waiver

determination."