CMS Pub. 100-06, ch. 3, § 200.5.4

Decisions:

(Rev.12509; Isuued:02-15-24; Effective: 07-01-24; Implementation: 07-01-24)

Exhibit 5:

Date:

Original Demand Letter Number:

Reference Number:

Provider Name:

This letter is in reference to the [Administrative Law Judge or subsequent levels]

decisions on [DATE], for the overpayment, [AMOUNT] issued to you on [DATE OF

DEMAND]. According to our records, the new revised overpayment amount is

[AMOUNT]. Following the final decision by the ALJ, when the debt has not been paid in

full, we will begin Recoupment immediately whether or not you appeal to the next level.

Interest continues to accrue and will be assessed for the total amount due in accordance

with 42 CFR § 405.378.

Rebuttal Process:

Under our existing regulations 42 CFR Sections 405.374, within 15 days from the

date of this letter, providers and suppliers will have the opportunity to submit a

rebuttal statement.

The rebuttal process provides the debtor the opportunity before the suspension,

offset, or recoupment takes effect, to submit any 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 appeal 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 may file an appeal request with the Medicare Appeals Council, the fourth level of

administrative appeal, following the instructions included in the ALJ decision (see also,

42 CFR §§405.1100-1130). Recoupment proceeds regardless of the filing for a Council

review. If there is no confirmation on the next appeal request, this debt may be referred to

Treasury.

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 (www.contractor.com).

Please refer to your Initial Demand and Intent to Refer letters for any other

information

not disclosed in this letter.

Thank you

Contractor Name

xxx-xxx-xxxx