CMS Pub. 100-06, ch. 3, § 200.4.5

Exhibit 4: Reconsideration Revised Overpayment Demand Letter:

Month, Date, Year

Provide Number or NPI Number

Original Demand Letter Reference Number:

Dear [Provider Name],

This letter is in reference to the Medicare reconsideration [Decision], dated [DATE], for

the overpayment of [AMOUNT] issued to you on [DATE OF DEMAND].

According to our records, the balance on the Principal amount is [AMOUNT] and the

Interest amount is [AMOUNT]. A payment is due totaling [AMOUNT] by [DATE].

We can begin to recoup no earlier than 30 days from the date of this letter. Interest will

continue to accrue and will be assessed for the total amount due until the debt is collected

in full as explained in your demand letter in accordance with 42 CFR § 405.378.

[After adjusting the ARs on the unfavorable amounts due to a Partially Favorable

decision, Contractors shall modify this letter to show the claims that can be

appealed, for example:

According to our records, due to the Partially Favorable decision the overpayment was

collected in full. [Refer to your reconsideration appeal decision letter for the listing

of the unfavorable claims]

Rebuttal Process:

Under our existing regulations at 42 CFR § 405.374, providers and other suppliers

will have 15 days from the date of this demand letter to submit a statement of

opportunity to rebuttal. The rebuttal process provides the debtor the opportunity,

before the suspension, offset, or recoupment takes effect, to submit a statement (to

include any pertinent information) as to why it should not be put into effect

on the date specified in the notice. A rebuttal is not intended to request a review of

supporting medical documentation nor to express disagreement with the

overpayment decision.

A rebuttal shall not duplicate the reconsideration process. This is not an appeal of

the overpayment determination. Our office will advise you of our decision 15 days

from the mailroom stamped receipt date of your request.

The rebuttal statement does not cease recoupment activities consistent with Section

935(f)(2) of the Medicare Modernization Act (MMA).

If you wish to appeal this decision:

You can appeal the unfavorable amount if you disagree with this overpayment decision,

to the Administration Law Judge (ALJ) 60 days from the date of receipt of the

reconsideration. An Appeal is a review performed by people independent of those who

have reviewed your claim so far. Refer to your reconsideration appeal decision letter for

the listing of the unfavorable claims.

Recoupment proceeds regardless of the filing for an ALJ hearing. Following the final

decision by

the QIC, if the debt has not been paid in full, we will begin or resume recoupment

whether or not you appeal to the next level after 30 days from the date of this letter due to

the QIC decision or dismissal. [Disregard this paragraph if debt was paid in full

prior to or after recalculation]

If you have already sent payment, we thank you and ask that you disregard this letter. If

you are unable to repay the amount in full, please visit our website for instructions

on an Extended Repayment schedule [MAC WEBSITE].

Please refer to your initial demand letter for any other information not disclosed in

this letter.

Thank you,

[CONTRACTOR NAME]

[CONTRACTOR PHONE]

NOTE: For revised letters on overpayments with a zero balance or paid in full, the

Rebuttal Statement

is not necessary.