US · guidance
CMS Pub. 100-06, ch. 3, § 200.4.2
The Reconsideration Receipt Notice Example
Exhibit 3: Reconsideration Receipt Notice
Current Date
Provider Name
Address
City, State ZIP Code
Provider Number:
Account Receivable Number:
Dear Provider Name,
This letter serves as a notification that [Contractor name] received confirmation that the
Qualified Independent Contractor (QIC) [Name] has validated your request for a
reconsideration review.
All collection processes have ceased on the unpaid balance of the accounts receivable unless
you have entered into an extended repayment schedule or an immediate recoupment
agreement.
Interest will continue to accrue on any outstanding unpaid balance of the overpayment as
Explained in your demand letter.
You will receive a reconsideration decision letter after the QIC has rendered its decision.
If you have any questions, please contact our office at the appropriate number listed below.
you may also visit us at [website].
Sincerely,
(Name and title)
History
(Rev. 12261; Issued:09-22-23, Effective: 12-11-23; Implementation: 12-11-23)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
edeec0b8d5345900e7dc724d61229f195fb0b529f59fdd9af3e71e25abcb33e8
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