CMS Pub. 100-06, ch. 4, § 20.2

It is CMS’ responsibility to protect the Trust Fund and replenish any overpaid funds. In this section,

contractors are given templates to model when sending providers and suppliers a request for payment.

EXHIBIT 1- INITIAL DEMAND LETTER - NON-935–

(Rev .316, Issued: 05-24-19, Effective: 10-01-19, Implementation: 10-07-19)

Contractors shall use the appropriate template below:

A. Contractors on HIGLAS shall use the list below for the appropriate system generated letters.

1. (BPROV1.pdf) Part B Provider/Supplier Initial Demand Letter

2. (BPROV1VA.pdf) Provider/Supplier Voluntary Returned Check 1st demand letter

3. (BPROV1N.pdf) Part B Provider/Supplier Notify Initial Demand Letter

4. (BPROV1V.pdf) Part B Provider/Supplier Voluntary Refund 1st Demand Letter

5. (APROV1.pdf) Part A Aggregate Claims Demand Letter

6. (APROV-CLA.pdf) Part A No Appeal

B. Contractors not on HIGLAS and Manual letters shall use this letter as your template.

RE: Initial Demand Letter

Provider/Supplier Name:

Provider/Supplier Number:

&

Overpayment Amount:

&HINVOICE_AMOUNT

Outstanding Balance:

&DEMAND_AMOUNT

C. Contractors shall use the appropriate first paragraph below:

Dear Sir/Madam:

PART B Provider or Supplier Demand Letter (BPROV1.pdf in HIGLAS)

This is to let you know that you have received a Medicare payment in error, which has resulted in

an overpayment to you of &HINVOICE_AMOUNT. The attached documentation explains how

this happened.

NOTE: If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding please

follow the instructions found at the end of this letter.

Or,

PART B Provider or Supplier Notify 1st Demand Letter (BPROV1N.pdf in HIGLAS)

We appreciate your recent inquiry regarding a Medicare payment that you believe was paid in error. Our

analysis found that the overpaid amount was &DEMAND_AMOUNT. The attached documentation

explains how this happened. We thank you for bringing this overpayment to our attention.

NOTE: If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding please

follow the instructions found at the end of this letter.

Or,

PART B Provider or Supplier Voluntary Returned/Refund 1st Demand, (BPROV1VA.pdf in

HIGLAS) or (BPROV1V.pdf in HIGLAS)

We have received your check in the amount of &INVOICE_RECEIPT_AMOUNT. We thank you for

bringing this overpayment to our attention. While we appreciate you submitting payment to us, our

review found that the overpaid amount was &HINVOICE_AMOUNT. The attached documentation

explains how this happened. Please remit the additional &INVOICE_BALANCE_AMOUNT.

NOTE: If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding please follow

the instructions found at the end of this letter.

Or,

PART A (Non-935) Aggregate Claims Demand Letter (APROV1.pdf in HIGLAS)

Claims adjustments were entered in our system under provider &HPROVIDER_NAME.

Additional adjustments were made to the claims, and a balance in the amount of &DEMAND_

AMOUNT has been outstanding for 60 days. As this amount has not been recouped through claims

submission, the purpose of our letter is to request that this amount be repaid to our office. The attached

documentation explains how this happened.

NOTE: If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding please follow

the instructions found at the end of this letter.

Or,

PART A No Appeal Claims Demand Letter (APROVNOAPPEAL1.pdf in HIGLAS)

Claims adjustments were entered in our system under provider &HPROVIDER_NAME and a balance in

the amount of &DEMAND_ AMOUNT is due. The purpose of our letter is to request that this amount be

repaid to our office. The attached documentation explains how this happened.

NOTE: If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding please follow the

instructions found at the end of this letter.

D. Contractors shall include the following language below in all initial letters after the first

paragraph.

Why you are responsible:

You are responsible for following correct Medicare filing procedures and must use care when billing

and accepting payment. You are responsible for repayment in this matter based upon one or both of the

following criteria:

1. You billed and/or received payment for services for which you should have known you were

not entitled to receive payment. Therefore, you are not without fault and are responsible for

repaying the overpayment amount.

2. You received overpayments resulting from retroactive changes in the Medicare Physician

Fee Schedule and/or changes mandated by legislation.

If you dispute this determination, please follow the appropriate appeals process listed below. (Applicable

authorities: § 1870(b) of Social Security Act; sub§ 405.350 - 405.359 of Title 42, sub§ 404.506 - 404.509,

404.510a and 404.512 of Title 20 of the United States Code of Federal Regulations.) [This appeal

paragraph is to be excluded in No-Appeal demand letters.]

Rebuttal Process:

Under our existing regulations 42 CFR § 405.374, providers and suppliers will have 15 days from the

date of this demand letter to submit a statement of rebuttal. 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 redetermination

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.

Interest Assessment:

If you do not refund in 30 days:

In accordance with 42 CFR 405.378, simple interest at the rate of &AR_INTEREST_RATE % will be

charged on the unpaid balance of the overpayment, beginning on the 31st day. Interest is calculated in

30-day periods and is assessed for each full 30-day period that payment is not made on time. Thus, if

payment is received 31 days from the date of final determination, one 30-day period of interest will be

charged. Each payment will be applied first to accrued interest and then to principal. After each

payment, interest will continue to accrue on the remaining principal balance, at the rate of

&AR_INTEREST_RATE %. In addition, please note that Medicare rules require that payment be

either received in our office by &LETTER_DATE_29 (United States Postal Service Postmark) for the

payment to be considered timely. A metered mail postmark received in our office after

&LETTER_DATE_29 will cause an additional month's interest to be assessed on the debt.

Payment by Recoupment:

If payment in full is not received by &LETTER_DATE_40 (&LETTER_DATE_15 for Part A non-

935), payments to you can be recouped (recoupment) until payment in full is received if you haven't

submitted an acceptable ERS request, an immediate recoupment request, and/or a valid and timely

appeal is received.

Make a payment or Arrange for payments:

What you should do:

Please return the overpaid amount to us by &LETTER_DATE_29 and no interest charge will be

assessed. Make the check payable to Medicare Part A and send it with a copy of this letter to:

&CONTRACTOR_NAME

&REVIEW_ADDRESS1

&REVIEW_ADDRESS2

&REVIEW_CITY, &REVIEW_STATE &REVIEW_POSTAL_CODE

In addition, please note that Medicare rules require that payment be either received in our office by,

&LETTER_DATE_29, or United States Postal Service postmark by that date, for the payment to be

considered timely. A metered mail postmark received in our office after &LETTER_DATE_29 will

cause an additional month's interest to be assessed on the debt.

If you are unable to make refund of the entire amount at this time, advise this office immediately with

a request for an extended repayment schedule (ERS) so that we may determine if you are eligible for

one. Any repayment schedule (where one is approved) would run from the approval date. You can

visit our website at [&CONTRAC TOR_URL] for ERS instructions and forms.

Immediate Recoupment:

If Provider is enrolled in Immediate Recoupment-

NO FURTHER ACTION IS REQUIRED BY YOU. You have previously elected to have your

overpayment(s) repaid through the Immediate Recoupment process. Based on this payments to you will

begin to be recouped on &LETTER_DATE_16 until payment is received in full. If the debt is not

collected in full before day 31, interest will continue to accrue until the debt is collected in full.

If Provider is NOT enrolled in Immediate Recoupment-

TO SIMPLIFY THE REPAYMENT PROCESS, reduce the extra work and cost associated with mailing

your repayment each time, you may elect to have automatic immediate recoupments for ALL overpayments

by requesting the Immediate Recoupment process for All Current and Future Accounts Receivable. This

will automatically begin recoupment starting on day 16 for ALL future accounts receivable. When the initial

request is received after day 16 the debt shall be placed in an immediate recoupment status. If the debt is not

collected in full before day 31, interest will continue to accrue until the debt is collected in full.

You must specify whether you are submitting:

1. A request on the current demanded overpayment (all accounts receivables within this demand letter) and

ALL FUTURE OVERPAYMENTS; or

2. A one-time request on this current demanded overpayment (all accounts receivables) addressed in this

demand letter only.

This process is voluntary and for your convenience.

You can visit our website at {MAC site} for the Immediate Recoupment

Request instructions.

You may contact this office for information on how to fax your request.

You may contact this office for information on how to fax your request. (Immediate recoupment already in

effect for Part A non-935.)

If you wish to appeal this decision: [This appeal paragraph is to be excluded in No-Appeal demand

letters.]

If you disagree with this overpayment decision, you may file an appeal. Please refer to the original

remittance advice for additional instruction. An appeal is a review performed by people independent

of those who have reviewed your claim so far. The first level of appeal is called a redetermination.

You must file your request for a redetermination within 120 days of the date you receive this letter.

Unless you show us otherwise, we assume you received this letter 5 days after the date of this letter.

Please send your request for redetermination to:

&CONTRACTOR_NAME &REVIEW_ADDRESS1 &REVIEW_ADDRESS2

&REVIEW_CITY, &REVIEW_STATE &REVIEW_POSTAL_CODE

Medicaid Offset:

If this matter is not resolved, CMS may instruct the Medicaid State Agency to withhold the Federal

share of any Medicaid payments that may be due you or related facilities until the full amount owed

to Medicare is recouped, Title 42 CFR, § 447.30(g). These recoveries will be in addition to any

recoupments from other Medicare funds due you until the full amount owed to Medicare is

recovered.

Right to Inspect Records Prior to Referral to Treasury:

In the event an ITR letter is sent, you have the right to inspect and copy all records pertaining to your debt.

In order to present evidence or review the CMS records, you must submit a written request to the address

below. Your request must be received within 60 calendar days from the ITR letter date. In response to a

timely request for access to CMS’ records, you will be notified of the location and time when you can

inspect and copy records related to this debt. Interest will continue to accrue during any review period.

Therefore, while review is pending, you will be liable for interest and related late payment charges on

amounts not paid by the due date identified above.

For Individual Debtors Filing a Joint Federal Income Tax Return:

The Treasury Offset Program automatically refers debts to the Internal Revenue Service (IRS) for Offset.

Your Federal income tax refund is subject to offset under this program. If you file a joint income tax

return, you should contact the IRS before filing your tax return to determine the steps to be taken to

protect the share of the refund which may be payable to the non-debtor spouse.

For Debtors that Share a Tax Identification Number(s):

Section 1866(j)(6) of the Social Security Act authorizes the Secretary of Health and Human Services (the

Secretary) to make any necessary adjustments to the payments of an applicable provider or supplier who

shares a TIN with an obligated provider or supplier, one that has an outstanding Medicare overpayment.

The Secretary is authorized to adjust the payments of such a provider or supplier regardless of whether it

has been assigned a different billing number or National Provider Identification Number (NPI) from that

of the provider or supplier with the outstanding Medicare overpayment.

Federal Salary Offset:

If the facility ownership is either a sole proprietorship or partnership, your individual salary(s) may

be offset if you are, or become, a federal employee.

If You Have Filed a Bankruptcy Petition:

If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding, Medicare financial

obligations will be resolved in accordance with the applicable bankruptcy process. Accordingly, we

request that you immediately notify us about this bankruptcy so that we may coordinate with both the

Centers for Medicare & Medicaid Services and the Department of Justice so as to assure that we handle

your situation properly. If possible, when notifying us about the bankruptcy, please include the name

the bankruptcy is filed under and the district where the bankruptcy is filed.

Should you have any questions, please contact your overpayment representative at the following number:

CONTACT_PHONE_NUM_

We look forward to hearing from you shortly.

Sincerely,

Medicare A or B Recovery Unit

Enclosures: How This Overpayment Was Determined

EXHIBIT 2- INITIAL DEMAND LETTER - 935

(Rev. 316, Issued: 05-24-19, Effective: 10-01-19, Implementation: 10-07-19)

A. Contractors on HIGLAS shall use the list below for the appropriate system generated letters.

1. (APROV9351.pdf): Part-A Adjustment Initial Claims Demand letter

2. (BPROV9351.pdf): Part-B 935 Adjustment Initial Claims Demand letter

3. (APROVAGG9351.pdf): Part-A Aggregate Closure Initial Demand Letter

4. (BPROVAGG9351.pdf): Part-B Aggregate Closure Initial Demand Letter

5. (APROVRAC1.pdf): Part-A 935 RAC Adjustment Claims Demand Letter

6. (BPROVRAC1.pdf): Part-B 935 RAC Adjustment Claims Demand Letter

7. (APROVRACAGG1.pdf): Part-A 935 RAC Adjustment Claims Initial Demand Letter

8. (BPROVRACAGG1.pdf): Part-B 935 RAC Adjustment Claims Initial Demand Letter

B. Contractors not on HIGLAS shall use this letter as your template.

Letter Number: Date:

&HPROVIDER_NAME

&HPROVIDER_ADDRESS1

&HPROVIDER_CITY, &HPROVIDER_STATE

HPROVIDER_POSTAL_CODE

INITIAL REQUEST

[Contractors shall use the appropriate reference below for demanded 935 overpayments.] RE:

MMA 935 –

Overpayment Amount

Dear Sir/Madam,

Contractors shall use the appropriate first paragraph below for all Initial Demands letters except Recovery

Audit Contractors (RAC).

This letter is to inform you that you have received a Medicare payment in error, which has resulted in an

overpayment subject to § 935(f) (2) of the Medicare Modernization Act (MMA), § 1893(f) (2) of the

Social Security Act, Limitation on Recoupment, in the amount & DEMAND_ AMOUNT. The purpose

of this letter is to request that this amount be repaid to our office. The attached explains how this

happened.

NOTE: If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding please

follow the instructions found at the end of this letter.

(RAC Demand Letter Language only)

This finding was a result of a Recovery Audit Program review. If you have any questions relating

to this letter or the recoupment process, you should contact us at:

&CONTRACT_STATE_TOLL_FREE_ &CONTRACT_STATE_TOLL_FREE_NUM. If you

have any questions relating to the review rationale or you feel that this finding is in error and

would like to submit additional documentation or discuss the issue further, please contact the

Recovery Auditor.

If you are unable to locate the name and contact information for the Recovery Auditor from

prior correspondence, please contact the Medicare Administrative Contractor, which is located

at the bottom of this page, for further information.

NOTE: If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding please

follow the instructions found at the end of this letter.

How This Overpayment Was Determined:

[When applicable on a Manual Letter, include explanation of the overpayment determination.]

[Contractor shall explain the authority for reopening the claims (i.e., consistent with 42 CFR 405.980

and Publication 100-04, Medicare Claims Processing Manual, chapter 34) and explain how the facts of

the case allowed you to reopen within the timeframes established in those sections.]

Why You Are Responsible:

You are responsible for following correct Medicare filing procedures. In this situation, you billed and/or

received payment for services you should have known you were not entitled to. Therefore, you are not

without fault and are responsible for repaying the overpayment amount. If you dispute this

determination, please follow the appropriate appeals process listed below. Applicable authorities: §

1870(b) (c) of the Social Security Act; Sub§ 405.350 - 405.359 of Title 42 CFR, Sub§ 404.506 -

404.509, 404.510a and

404.512 of Title 20 of the United States Code of Federal Regulations.

This amount is subject to § 935(f) (2) of the Medicare Modernization Act (MMA) (section 1893(f) (2) of

the Social Security Act), Limitation on Recoupment (42 CFR 405.379).

Rebuttal Process:

Under our existing regulations at 42 CFR § 405.374, Providers or Suppliers will have 15 days from the

date of this demand letter to have an opportunity for rebuttal by submitting a statement. The rebuttal

process provides the debtor the opportunity, before the suspension of payment, 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 as a request for the review

supporting medical documentation nor to express disagreement with the overpayment decision. A

rebuttal shall not duplicate the redetermination process. This is not an appeal of the overpayment

determination. The limitation on recoupment under § 1893 (f) (2) (a) of the Social Security Act does

not apply to rebuttal requests. Our office will advise you of our decision 15 days from the mailroom-stamped receipt date of your request.

Interest Assessment:

If you do not pay the full amount in 30 days:

In accordance with 42 CFR 405.378, simple interest at the rate of &AR_INTEREST_RATE percent will be

charged on the unpaid balance of the overpayment, beginning on the 31st day. Interest is calculated in 30-day

periods and is assessed for each full 30-day period that payment is not made on time.

Thus, if payment is received 31 days from the date of final determination, one 30-day period of interest

will be charged. Each payment will be applied first to accrued interest and then to principal. After each

payment, interest will continue to accrue on the remaining principal balance, at the rate of

&AR_INTEREST_RATE percent. A metered mail postmark received in our office after

&LETTER_DATE_29 will cause an additional month's interest to be assessed on the debt.

In addition, please note that Medicare rules require that payment be either received in our office by

&LETTER_DATE_29 or United States Postal Service Postmark by that date for the payment to be

considered timely.

Suspended Funds Applied To The Overpayment and Has a Remaining Outstanding Balance:

If the suspended funds are insufficient to fully eliminate any overpayment, and the provider or supplier

meets the requirements of 42 CFR § 405.379 "Limitation on Recoupment" provision under §1893(f) (2) of

the Act, then the provider or supplier is subject to 935 Appeals rights and will be available for offset after

41 days on the remaining balance still owed to CMS. (See 42 CFR § 405.372(e) for more information.)

Payment by Recoupment:

If payment in full is not received by &LETTER_DATE_29 (date of the notification), payments to you can

be recouped (recoupment) until payment in full is received if you haven't submitted an acceptable ERS

request, an immediate recoupment request, and/or a valid and timely appeal is received.

Make a Payment or Arrange for Payments:

What You Should Do:

Please return the overpaid amount to us by &LETTER_DATE_29 and no interest will be

assessed. We request that you refund this amount in full.

Make the check payable to Medicare [Part A] or [Part B] and send it with a copy of this letter to:

&CONTRACTOR_NAME

&CHECK_ADDRESS1

&CHECK_CITY, &CHECK_STATE &CHECK_POSTAL_CODE

If you are unable to make refund of the entire amount at this time, advise this office immediately

with a request for an extended repayment schedule (ERS) so that we may determine if you are

eligible for one. Any repayment schedule (where one is approved) would run from the approval

date. You can visit our website at [&CONTRAC TOR_URL] for ERS instructions and

forms.

Immediate Recoupment:

If Provider is enrolled in Immediate Recoupment-

NO FURTHER ACTION IS REQUIRED BY YOU. You have previously elected to have your

overpayment(s) repaid through the Immediate Recoupment process. Based on this payments to you will

begin to be recouped on &LETTER_DATE_16 until payment is received in full. If the debt is not

collected in full before day 31, interest will continue to accrue until the debt is collected in full.

If Provider is NOT enrolled in Immediate Recoupment-

TO SIMPLIFY THE REPAYMENT PROCESS, reduce the extra work and cost associated with mailing

your repayment each time, you may elect to have automatic immediate recoupments for ALL overpayments

by requesting the Immediate Recoupment process for All Current and Future Accounts Receivable. This

will automatically begin recoupment starting on day 16 for ALL future accounts receivable. When the initial

request is received after day 16 the debt shall be placed in an immediate recoupment status. If the debt is not

collected in full before day 31, interest will continue to accrue until the debt is collected in full.

You must specify whether you are submitting:

1. A request on the current demanded overpayment (all accounts receivables within this demand letter) and

ALL FUTURE OVERPAYMENTS; or

2. A one-time request on this current demanded overpayment (all accounts receivables) addressed in this

demand letter only.

This process is voluntary and for your convenience.

You can visit our website at {MAC site} for the Immediate Recoupment

Request instructions.

You may contact this office for information on how to fax your request.

This process is voluntary and for your convenience. Your request must specifically state you understand

you are waiving potential receipt of interest payment pursuant to § 1893(f) (2) for the overpayments.

Note: Such interest may be payable for certain overpayments reversed at the ALJ level or

subsequent levels of appeal.

If You Wish To Appeal This Decision:

If you disagree with this overpayment decision, you may file an appeal. An appeal is a review performed

by people independent of those who have reviewed your claims. The first level of appeal is called a

redetermination. You must file your request for a redetermination 120 days from the date of this letter.

However, if you wish to avoid recoupment from occurring, you need to file your request for

redetermination within 30 days from the date of this letter, as described above. Unless you show us

otherwise, we assume you received this letter within 5 days of the date of this letter.

Please send your request for redetermination to:

&CONTRACTOR_NAME - 935 APPEALS

REDETERMINATION &REVIEW_ADDRESS1

&REVIEW_CITY, &REVIEW_STATE &REVIEW_POSTAL_CODE

How to Stop Recoupment:

Even if the overpayment and any assessed interest has not been paid in full, you can temporarily stop

Medicare from recouping any payments. If you act quickly and decidedly, Medicare will stop

recoupment at two points.

First Opportunity: We must receive a valid and timely request for a redetermination within 30 days

from the date of this letter. We will stop or delay recoupment pending the results of an appeal. To assist

us in expeditiously stopping the recoupment process, we request that you clearly indicate on your appeal

request that this is a 935 overpayment appeal for a redetermination.

Second Opportunity: If the redetermination decision is (1) unfavorable, we will begin to recoup no

earlier than the 60th day from the date of the Medicare redetermination notice (Medicare Appeal

Decision Letter); or (2) if the decision is partially favorable, we will begin to recoup no earlier than the

60th day from the date of the Medicare revised overpayment Notice/Revised Demand Letter. Therefore,

it is important to act quickly and decidedly to limit recoupment by submitting a valid and timely request

for reconsideration within 60 days of the appropriate notice/letter. The address and details on how to

file a request for reconsideration will be included in the Redetermination decision letter.

What Happens Following a Reconsideration By a Qualified Independent Contractor (QIC):

Following a decision or dismissal 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, Administrative Law Judge (ALJ).

NOTE: Even when recoupment is stopped, interest continues to accrue.

Medicaid Offset:

If this matter is not resolved, CMS may instruct the Medicaid State Agency to withhold the Federal share

of any Medicaid payments that may be due you or related facilities until the full amount owed to

Medicare is recouped; Title 42 CFR, § 447.30(g). These recoveries will be in addition to any

recoupments from other Medicare funds due you until the full amount owed to Medicare is recovered.

Right to Inspect Records Prior to Referral to Treasury:

In the event an Intent to Refer (ITR) letter is sent, you have the right to inspect and copy all records

pertaining to your debt. In order to present evidence or review the CMS records, you must submit a

written request to the address below. Your request must be received within 60 calendar days from the

ITR letter date. In response to a timely request for access to CMS’s records, you will be notified of the

location and time when you can inspect and copy records related to this debt. Interest will continue to

accrue during any review period. Therefore, while review is pending, you will be liable for interest and

related late payment charges on amounts not paid by the due date identified above.

For Individual Debtors Filing a Joint Federal Income Tax Return:

The Treasury Offset Program automatically refers debts to the Internal Revenue

Service (IRS) for Offset. Your Federal income tax refund is subject to offset under this program. If

you file a joint income tax return, you should contact the IRS before filing your tax return to determine the

steps to be taken to protect the share of the refund, which may be payable to the non-debtor spouse.

For Debtors That Share a Tax Identification Number (TIN):

Section 1866(j)(6) of the Social Security Act authorizes the Secretary of Health and Human Services (the

Secretary) to make any necessary adjustments to the payments of an applicable provider or supplier who

shares a TIN with an obligated provider or supplier, one that has an outstanding Medicare overpayment.

The Secretary is authorized to adjust the payments of such a provider or supplier regardless of whether it

has been assigned a different billing number or National Provider Identification Number (NPI) from that

of the provider or supplier with the outstanding Medicare overpayment.

Federal Salary Offset:

If the facility ownership is either a sole proprietorship or partnership, your individual salary(s) may

be offset if you are, or become, a federal employee.

If You Have Filed a Bankruptcy Petition:

If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding, Medicare financial

obligations will be resolved in accordance with the applicable bankruptcy process. Accordingly, we

request that you immediately notify us about this bankruptcy so that we may coordinate with both the

Centers for Medicare & Medicaid Services and the Department of Justice to assure that we handle your

situation properly. If possible, when notifying us about the bankruptcy, please include the name the

bankruptcy is filed under and the district where the bankruptcy is filed.

Should you have any questions, please contact your overpayment consultant at the following:

&BUSINESS_PURPOSE_1

&CONTRACT_CONTACT_PHONE_NUM_

1

We look forward to hearing from you shortly.

Sincerely,

SELECT

Supervisor, Part A Overpayments &CONTRACTOR_NAME

Or,

Medicare Part B Recovery Unit

Enclosures

How This Overpayment Was Determined

EXHIBIT 3- INITIAL DEMAND LETTER- COST REPORTS FILED –

(Rev. 316, Issued: 05-24-19, Effective: 10-01-19, Implementation: 10-07-19)

A. Contractors on HIGLAS shall use the list below for the appropriate system generated letters.

1. (APROVCRASF1.pdf): Part-A As-Filed Cost Report Initial Demand letter

2. (APROVNONCRASF1.pdf): Part A Cost Report Initial Letter – Tentative Settlement

B. Contractors not on HIGLAS shall use this letter below as your template.

C. Use the appropriate reference below for the first paragraph.

INITIAL REQUEST

RECEIPT CONFIRMATION REQUESTED

RE: Initial Demand Letter Provider or Supplier Name:

Provider/Supplier Number: &

Overpayment Amount: &HINVOICE_AMOUNT

Outstanding Balance: & DEMAND_AMOUNT

Date:

Dear Mr. Smith:

Contractors shall use the appropriate paragraph for the cost report situation:

(NPR Issued)

On July 26, 20xx, we received your cost report for the fiscal year ending June 30, xxxx. We have fully

reviewed this report, and the results of our review have been incorporated in the enclosed copy of your

Notice of Program Reimbursement (dated August 21, 20xx). As explained in the Notice, we find that

the Valley Convalescent Center has been overpaid $ for the past fiscal year.

NOTE: If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding please

follow the instructions found at the end of this letter.

(Tentative Settlement)

On July 26, 20xx, we accepted your cost report for the fiscal year ending June 30, xxxx. We have

completed a preliminary review of this report and have determined that the Valley Convalescent Center

has been overpaid $ for this fiscal year.

NOTE: If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding please

follow the instructions found at the end of this letter.

(As Filed Cost Report)

On July 26, 20xx, we received your cost report for the fiscal year ending June 30, xxxx. The cost report,

as filed, reflects an overpayment of $ for this fiscal year. The Provider Reimbursement Manual

(PRM) Part 1, Chapter 24, section 2409.A (2) states that, when a cost report is filed indicating an

overpayment, a full refund shall accompany the cost report submission.

NOTE: If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding please

follow the instructions found at the end of this letter.

PLEASE MAIL TO:

&CONTRACTOR_NAME &CHECK_ADDRESS1 &CHECK_ADDRESS2

&CHECK_CITY, &CHECK_STATE &CHECK_POSTAL_CODE

The total of &DEMAND_AMOUNT should immediately be refunded in full. Your facility's check should

include your provider number and be made payable to &CONTRACTOR_NAME.

If payment in full is not received, payments to you will be withheld until payment in full is received or an

acceptable extended repayment request is received. If you have reason to believe that the withhold should

not occur, you must notify [contractor]. We will review your documentation, but will not delay

recoupment.

This is not an appeal of the overpayment determination.

Medicaid Offset

If this matter is not resolved within fifteen (15) days from the date of this letter, CMS may instruct the

Medicaid State Agency to withhold the Federal share of Title XIX of any Medicaid payments that may

be due you or related facilities until the full amount owed Medicare is recouped, Title 42 CFR, §

447.30(g). These recoveries will be in addition to any recoupments from other Medicare funds due you

until the full amount owed to Medicare is recovered. The appeal process is detailed in the Notice of

Program Reimbursement (NPR).

Interest Assessment:

In accordance with 42 CFR 405.378, simple interest at the rate of will be charged on the

unpaid balance of the overpayment beginning on the 31st day. Interest is calculated in 30-day periods

and is assessed for each full 30-day period that payment is not made in full. Thus, if payment is received

31 days from the date of final determination, one 30-day period of interest will be charged and will

continue to be assessed for full 30-day periods on any portion that remains outstanding until the debt is

paid in full.

Each payment will be applied first to accrued interest and then to principal. After each payment,

interest will continue to accrue on the remaining principal balance, at the rate of _.

Extended Repayment Request:

We request that you refund this amount in full. If you are unable to make refund of the entire amount at

this time, advise this office immediately so that we may determine if you are eligible for a repayment

schedule. (Refer to www.Mac.com for details and forms.) Any repayment schedule (where one is

approved) would run from the approval date. If we do not hear from you, your interim payments will be

withheld starting on the 16th day from the date of this letter, and applied towards the outstanding

overpayment balance.

Any amount withheld will not be refunded.

If You Have Filed a Bankruptcy Petition:

If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding, Medicare financial

obligations will be resolved in accordance with the applicable bankruptcy process. Accordingly, we

request that you immediately notify us about this bankruptcy so that we may coordinate with both the

Centers for Medicare & Medicaid Services and the Department of Justice so as to assure that we handle

your situation properly. If possible, when notifying us about the bankruptcy, please include the name

the bankruptcy is filed under and the district where the bankruptcy is filed.

For Debtors That Share a Tax Identification Numbers:

Section 1866(j)(6) of the Social Security Act authorizes the Secretary of Health and Human Services (the

Secretary) to make any necessary adjustments to the payments of an applicable provider or supplier who

shares a TIN with an obligated provider or supplier, one that has an outstanding Medicare overpayment.

The Secretary is authorized to adjust the payments of such a provider or supplier regardless of whether it

has been assigned a different billing number or National Provider Identification Number (NPI) from that

of the provider or supplier with the outstanding Medicare overpayment.

Should you have any questions please contact at . We expect to hear from you

shortly.

Sincerely,

(Name and Title)

Enclosure

(Name and Title)

Enclosure

EXHIBIT 4- INITIAL DEMAND LETTER – UNFILED COST REPORT

(Rev. 316, Issued: 05-24-19, Effective: 10-01-19, Implementation: 10-07-19)

A. Contractors on HIGLAS shall use the list below for the appropriate system generated letters.

1. (APROVNONCRASF1.pdf): Part-A Non As-Unfiled Cost Report Initial Demand Letter

B. Contractors not on HIGLAS shall use this letter as your template.

(Mailed 7 calendar days after cost report was

due.) Date:

INITIAL DEMAND LETTER

[Provider name] [Mail to Name] [Mail to Address 1] [Mail to Address 2] [City} {State} {Zip]

RECEIPT CONFIRMATION REQUESTED

RE: Late Medicare Cost

Report Provider Name: [DBA

Name] Provider Number:

[xxxxxxxx]

Fiscal Year End: [Month, Day, Year]

Dear [Title] [Last Name]

Contractors shall use the appropriate paragraph for the cost report situation:

(Unfiled Cost Report)

We have not received the cost report for [DBA Name], provider number [xxxxxxx] for the period ending

[month/day/year]. Under Title 42 Code of Federal Regulations (CFR), § 413.24, cost reports are due by

the last day of the fifth (5th) month following the close of the provider’s cost report year or 30 days after

receipt of valid Provider Statistical and Reimbursement (PS&R) reports from the contractor, whichever

is later. Your report is now late, as it was due [month/day/year].

NOTE: If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding please

follow the instructions found at the end of this letter.

(Home Office Cost Report is Unfiled)

We have not received the home office cost statement from ______. According to our records,

serves as the home office for your facility. Since the home office cost statement remains unfiled, the

amount stated on your filed cost report for the fiscal year ending for home office costs has been

disallowed. This disallowance will continue until the home office submits the home office cost statement.

NOTE: If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding please

follow the instructions found at the end of this letter.

Deemed Overpayment:

As a cost report has not been received from your facility, all interim and lump-sum payments made for

the fiscal period noted above are deemed an overpayment. The principal amount of the overpayment

related to this fiscal period is [$ xxxxxx.xx]. If you do not submit a cost report, please be advised that

this letter constitutes Federal Claims Collection Act (FCCA) notification that this amount is now

due and must be remitted to us within thirty (30) days from the date of this letter. Interest will be

assessed on any portion of this amount that is not paid timely in accordance with Title 42 CFR 405.378

(c) (1) (v).

If full payment is not received or arrangements made for an extended repayment schedule, we will take

all action(s) necessary to recover the full amount. You can visit our website at [&CONTRAC

TOR_URL] for ERS instructions and forms.

Suspension:

As your cost report has not been received timely, all payments to your facility have now been suspended

under the authority of Title 42 CFR § 405.371(d). Payments will not be resumed until an acceptable cost

report is received by us.

Interest Charges:

Interest is assessed on late cost reports and late payments under Title 42 CFR 405.378 (c) (1) (v):

1. Cost reports reflecting an amount due to the Medicare program must include the full amount owed

(including interest) from the day following the date the cost report was due to the date that the cost report

is filed.

2. If a late cost report reflects that there is an amount due Medicare and the full amount owed (including

interest) is not included with the cost report, interest will continue to accrue on the overpayment until it

is paid in full.

3. Additionally, when it is determined that an additional overpayment exists on a late-filed cost report,

through interim settlement or NPR, interest will be assessed on the overpayment from the day following

the date the cost report was due to the date the cost report is filed. If the subsequent overpayment is not

paid within thirty (30) days of the date of the first demand letter, additional interest will be assessed from

the date of the subsequent determination until the overpayment is paid in full. If the full amount is not

paid, any partial payments will be applied first to accrued interest and then to principal. After each

partial payment, interest will continue to accrue on the remaining principal balance.

Interest Computation:

The interest rate in effect at the time your cost report was due is [xx.xxx%]. This rate is applicable to any

overpayments related to the untimely filing of your cost report. Under Title 42 CFR § 405.378 (b) (2),

interest charges are assessed in thirty (30)-day periods. Thus, if payment is received 31 days from the date

of final determination, one 30-day period of interest will be assessed and for each full 30-day period until

the debt is paid in full.

Cost Report Submission:

Please attend to this matter immediately by mailing a copy of this letter together with: (1) A completed

cost report, together with any amounts due (principal and interest); (2) A complete refund of all interim

payments, the deemed overpayment (principal and interest), within thirty (30) days of the date of this

letter; or (3) A request for a repayment schedule of all interim payments, the deemed overpayment,

within fifteen (15) days of the date of this letter. Checks are to be made payable to [Contractor]. They

and/or your remittance advice should be annotated with your provider name, number, and cost report year

end that applies to the amount due.

[Prime Contractor] [Division or Group] [Routing, Room Number] [Mail To Address 1] [Mail To

Address 2] [City, State, Zip]

As you are aware, cost reports are subject to further review. There could be additional adjustments

required after completion of a review. Therefore, the records supporting this report are to be retained for

at least three (3) years from the date of the NPR.

For Debtors That Share Tax Identification Numbers:

Section 1866(j)(6) of the Social Security Act authorizes the Secretary of Health and Human Services (the

Secretary) to make any necessary adjustments to the payments of an applicable provider or supplier who

shares a TIN with an obligated provider or supplier, one that has an outstanding Medicare overpayment.

The Secretary is authorized to adjust the payments of such a provider or supplier regardless of whether it

has been assigned a different billing number or National Provider Identification Number (NPI) from that

of the provider or supplier with the outstanding Medicare overpayment.

Medicaid Offset:

If this matter is not resolved within fifteen (15) days from the date of this letter, CMS may instruct the

Medicaid State Agency to withhold the Federal share of any Medicaid payments that may be due you or

related facilities until the full amount owed Medicare is recouped, Title 42 CFR, § 447.30(g). These

recoveries will be in addition to any recoupments from other Medicare funds due you until the full amount

owed to Medicare is recovered.

If You Have Filed a Bankruptcy Petition:

If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding, Medicare financial

obligations will be resolved in accordance with the applicable bankruptcy process. Accordingly, we

request that you immediately notify us about this bankruptcy so that we may coordinate with both the

Centers for Medicare & Medicaid Services and the Department of Justice so as to assure that we handle

your situation properly. If possible, when notifying us about the bankruptcy, please include the name the

bankruptcy is filed under and the district where the bankruptcy is filed.

Termination of Medicare Provider Agreement:

Be advised that under Title XVIII, § 1866(b)(2)(A) of the Social Security Act, continued failure to

submit the required cost report may result in the termination of your Medicare provider agreement.

If you have submitted a cost report and any payment due Medicare, please disregard this letter. If you

have any questions concerning this letter, do not hesitate to call [Title] [Insert full name] at

[(xxx) xxx-xxxx].

Sincerely,

[Title] [Name] [Position Title]

Intent to Refer Letters:

EXHIBIT 5- INTENT TO REFER LETTER- NON-935 –

(Rev. 316, Issued: 05-24-19, Effective: 10-01-19, Implementation: 10-07-19)

Contractors shall use the appropriate template below:

A. Contractors on HIGLAS shall use the list below for the appropriate system generated letters.

1. (BPROV3.pdf) Part B Provider Intent to Refer

2. (APROV3.pdf) Part A Aggregate Claims Intent to Refer

B. Contractors not on HIGLAS shall use this letter as your template.

Note: Contractors shall use this template for manual letters and shall scan all letters for easy access.

Date: &LETTER

&LETTER_HEADER1 &LETTER_HEADER2

&LETTER_HEADER3 &LETTER_HEADER4

Letter Number: &LETTER_NUMBER

&HPROVIDER_NAME

&HPROVIDER_ADDRESS1

&HPROVIDER_ADDRESS2

&HPROVIDER_CITY, &HPROVIDER_STATE &HPROVIDER_POSTAL_CODE

&HPROVIDER_COUNTRY

RE: Overpayment Amount: &HINVOICE_AMOUNT Outstanding Balance:

&DEMAND_AMOUNT

Provider Number: &HPROVIDER_NUMBER

Notice of Intent to Refer Debt to the Department of Treasury's Debt Collection Center for Cross

Servicing and Offset of Federal Payments and Certain Eligible State Payments

Dear Sir/Madam:

On &DATE_OF_ORIGINAL_DEMAND_LETTER, we sent a letter requesting that you refund an

overpayment made to you in the amount of &HINVOICE_AMOUNT that resulted from claim(s) accounts

receivable(s). As of the date of this letter, we have not yet received payment, an application for an

extended repayment schedule, or have sufficient assigned Medicare claims been submitted for collection of

the balance. The outstanding amount due for this overpayment is &DEMAND_AMOUNT, which includes

a principal amount of &INVOICE_BALANCE_AMOUNT and interest assessed in the amount of

&INTEREST_BALANCE_AMOUNT.

Your debt to the Medicare Program is delinquent and, by way of this letter, we are providing

notice that your debt may be referred to the Department of Treasury's Debt Collection Center

(DCC) for Cross Servicing and Offset of Federal Payments. Your debt may be referred under

provisions of Federal Law, title 31 of the United States Code, § 3720A, which is a provision of the

Debt Collection Improvement Act of 1996.

NOTE: If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding please

follow the instructions found at the end of this letter.

Repayment

Your debt will not be referred to the Department of Treasury if you make payment in full. The past due

amount of &DEMAND_AMOUNT owed to the Medicare Program as of &LETTER_DT includes

interest accrued through &LAST_INTEREST_ACCRUAL_DATE. Interest is accrued monthly and is

added to the balance of the debt.

Your check or money order for the amount due should be made payable to Medicare and sent with a

copy of this letter to:

&CONTRACTOR_NAME &CHECK_ADDRESS1 &CHECK_ADDRESS2

&CHECK_CITY, &CHECK_STATE &CHECK_POSTAL_CODE

If you cannot make payment in full, you may be allowed to enter into an extended repayment

agreement if you are eligible under the requirements at 42 C.F.R. 401.607(c)(2). If you are interested

in an extended repayment agreement, please contact this office. Refer to your initial demand letter to

determine your rights to an appeal.

Referral To The U.S. Department of The Treasury for Collection

If your debt remains unpaid 60 days from the date of this letter, your debt will be referred to the United

States Department of the Treasury’s (the Treasury) Debt Management Services for Cross Servicing and

Offset of Federal Payments. Your debt will be referred under 31 U.S.C. 3711(g). The Treasury’s Debt

Management Services will use various tools to collect the debt, including offset of federal payments,

demand letters, phone calls, referral to a private collection agency, and referral to the U.S. Department of

Justice for litigation.

Due Process

You have the right to request an opportunity to inspect and copy records relating to the debt. This request

must be submitted in writing to the address listed below. You have the right to present evidence that all

or part of your debt is not past due or legally enforceable. In order to exercise this right, this office must

receive a copy of the evidence to support your position, along with a copy of this letter. You must submit

any evidence that the debt is not owed or legally enforceable within 60 calendar days of the date of this

letter. If, after sixty (60) calendar days from the date of this letter, we have not received such evidence,

your debt, if it is still outstanding and eligible for referral, may be referred to the Department of Treasury

or its designated Debt Collection Center for cross servicing/offset.

For Individual Debtors Filing a Joint Federal Income Tax Return

The Treasury Offset Program automatically refers debts to the IRS for offset. Your Federal income tax

refund is subject to offset under this program. If you file a joint income tax return, you should contact the

IRS before filing your tax return to determine the steps to be taken to protect the share of the refund, which

may be payable to the non-debtor spouse.

Overpayments from Debtors Who Share Tax Identification Numbers

Section 1866(j)(6) of the Social Security Act authorizes the Secretary of Health and Human Services (the

Secretary) to make any necessary adjustments to the payments of an applicable provider or supplier who

shares a TIN with an obligated provider or supplier, one that has an outstanding Medicare overpayment.

The Secretary is authorized to adjust the payments of such a provider or supplier regardless of whether it

has been assigned a different billing number or National Provider Identification Number (NPI) from that

of the provider or supplier with the outstanding Medicare overpayment.

Federal Salary Offset

If the facility ownership is either a sole proprietorship or partnership, your individual salary(s) may be

offset if you are or become a federal employee.

Medicaid Offset

If this matter is not resolved, CMS may instruct the Medicaid State Agency to withhold the Federal

share of any Medicaid payments that may be due you or related facilities until the full amount owed to

Medicare is recouped, per Title 42 CFR, § 447.30. These recoveries will be in addition to any

recoupment from other Medicare funds due you until the full amount owed to Medicare is recovered.

Bankruptcy

If you have filed bankruptcy and an automatic stay is in effect, you are not subject to offset while the

automatic stay is in effect. Documentation supporting your bankruptcy status, along with a copy of this

notice, must be forwarded to this office at the above address.

Should you have any questions, please contact your overpayment consultant at the following:

&BUSINESS_PURPOSE_1

&CONTRACT_CONTACT_PHONE_NUM_1

&BUSINESS_PURPOSE_2

&CONTRACT_CONTACT_PHONE_NUM_2

&BUSINESS_PURPOSE_3

&CONTRACT_CONTACT_PHONE_NUM_3

&BUSINESS_PURPOSE_4

&CONTRACT_CONTACT_PHONE_NUM_4

&BUSINESS_PURPOSE_5

&CONTRACT_CONTACT_PHONE_NUM_5

We look forward to hearing from you shortly.

Sincerely,

Medicare Recovery Unit

EXHIBIT 6- INTENT TO REFER LETTER - 935 -

(Rev. 316, Issued: 05-24-19, Effective: 10-01-19, Implementation: 10-07-19)

A. Contractors on HIGLAS shall use the list below for the appropriate system generated letters.

1. (APROV9353.pdf) Part A 935 Aggregate & Adjustment Claims Intent to Refer

2. (APROVRAC2.pdf) Part A 935 RAC Adjustment Claims Intent to Refer

3. (BPROV9353.pdf) Part B 935 Adjustment Claims Intent to Refer

4. (BPROVRAC2.pdf) Part B 935 RAC Adjustment Claims Intent to Refer

B. Contractors shall use the appropriate first paragraph below.

RE: Medicare Overpayment and Notice of Intent to Refer Debt to the Department of Treasury's

Debt Collection Center for Cross Servicing and Offset of Federal Payments and Certain Eligible

State Payments - MMA 935

Provider Name: &HPROVIDER_NAME Provider Number:

&HPROVIDER_NUMBER Outstanding Balance:

&DEMAND_AMOUNT

Dear Sir/Madam:

Part A and B overpayments subject to 935 (excluding RAC overpayments)

On &DATE_OF_ORIGINAL_DEMAND_LETTER, we sent a letter requesting that you refund an

overpayment subject to 935, Limitation on Recoupment. As of this date, we have not yet received

payment, a 935 appeal request, or an application for an extended repayment schedule and insufficient

assigned Medicare claims have been submitted for collection of the balance. The outstanding amount due

for this overpayment is &DEMAND_AMOUNT, which includes a principal amount of

&INVOICE_BALANCE_AMOUNT and interest assessed in the amount of

&INTEREST_BALANCE_AMOUNT.

NOTE: If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding please

follow the instructions found at the end of this letter.

Or,

PART A and B 935 RAC Adjustment Claims

On &DATE_OF_ORIGINAL_DEMAND_LETTER, we sent a letter requesting that you refund a

Recovery Auditor-identified overpayment subject to 935, Limitation on Recoupment. As of this date, we

have not yet received payment, a 935 appeal request, or an application for an extended repayment schedule

and insufficient assigned Medicare claims have been submitted for collection of the balance. The

outstanding amount due for this overpayment is &DEMAND_AMOUNT, which includes a principal

amount of &INVOICE_BALANCE_AMOUNT and interest assessed in the amount of

INTEREST_BALANCE_AMOUNT.

NOTE: If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding please

follow the instructions found at the end of this letter.

[Contractors shall include the following language in all ITR-935 letters after the first

paragraph.]

Your debt to the Medicare Program is delinquent and, by this letter, we are providing notice that your debt

will be referred to the Department of Treasury's Debt Collection Center (DCC) for Cross Servicing and

Offset of Federal Payments. This could occur should the amounts recovered through withholding (offset)

of your claims be insufficient to satisfy the monthly amount of your extended repayment schedule or the

amount needed to be current on the extended repayment schedule. Your debt will be referred under

provisions of federal law, title 31 of the United States Code, § 3720A, which is a provision of the Debt

Collection Improvement Act of 1996.

The Debt Collection Improvement Act of 1996 (DCIA) requires Federal agencies to refer delinquent debt

to the Department of Treasury and/or a designated Debt Collection Center (DCC) for collection through

cross servicing and/or the Treasury Offset Program (TOP). Under the offset program, delinquent Federal

debts are collected through offset of other Federal agency payments you may be entitled to, including the

offset of your income tax return through the Internal Revenue Service (IRS). The TOP offsets can also be

taken from eligible state payments you are entitled to.

The DCC shall use various tools to collect the debt, including offset, demand letters, phone calls, referral

to a private collection agency and referral to the Department of Justice for litigation. Other collection

tools available, which may be used, include Federal salary offset and administrative wage garnishment.

If the debt is discharged, it may be reported to the IRS as potential taxable income.

During the collection process, interest shall continue to accrue on the debt and you shall remain

legally responsible for any amount not satisfied through the collection efforts.

For Individual Debtors Filing a Joint Federal Income Tax Return

The Treasury Offset Program automatically refers debt to the IRS for offset. Your Federal income tax

refund is subject to offset under this program. If you file a joint income tax return, you should contact

the IRS before filing your tax return to determine the steps to be taken to protect the share of the refund,

which may be payable to the non-debtor spouse.

Overpayments from Debtors Who Share Tax Identification Numbers

Section 1866(j)(6) of the Social Security Act authorizes the Secretary of Health and Human Services (the

Secretary) to make any necessary adjustments to the payments of an applicable provider or supplier who

shares a TIN with an obligated provider or supplier, one that has an outstanding Medicare overpayment.

The Secretary is authorized to adjust the payments of such a provider or supplier regardless of whether it

has been assigned a different billing number or National Provider Identification Number (NPI) from that

of the provider or supplier with the outstanding Medicare overpayment.

Federal Salary Offset

If the facility ownership is either a sole proprietorship or partnership, your individual salary(s) may

be offset if you are or become a federal employee.

Medicaid Offset

If this matter is not resolved, CMS may instruct the Medicaid State Agency to withhold the

Federal share of any Medicaid payments that may be due you or related facilities until the full amount

owed to Medicare is recouped, Title 42 CFR, § 447.30(g). These recoveries will be in addition to any

recoupment from other Medicare funds due you until the full amount owed to Medicare is recovered.

Please read the following instructions carefully to determine what action you should take to avoid

referral for cross servicing/offset.

Due Process

You have the right to request an opportunity to inspect and copy records relating to the debt. This request

must be submitted in writing to the address listed below. You have a right to present evidence that all or

part of your debt is not past due or legally enforceable. In order to exercise this right, this office must

receive a copy of the evidence to support your position, along with a copy of this letter. You must submit

any evidence that the debt is not owed or legally enforceable within 60 calendar days of the date of this

letter. If, after sixty (60) calendar days from the date of this letter, we have not received such evidence,

your debt, if it is still outstanding and eligible for referral, shall be referred to the Department of Treasury

or its designated DCC for cross servicing/offset.

Repayment

Your debt shall not be referred to the Department of Treasury if you make payment in full. The past due

amount owed to the Medicare Program as of the date of this letter includes current accrued interest.

Interest is accrued monthly and is added to the balance of the debt. Your check or money order for the

amount due should be made payable to:

&CONTRACTOR_NAME &CHECK_ADDRESS1 &CHECK_ADDRESS2

&CHECK_CITY, &CHECK_STATE &CHECK_POSTAL_CODE

Include a copy of this letter with your payment.

If you cannot make payment in full, you may be allowed to enter into an extended repayment

agreement if you are eligible under the extended repayment requirements at 42 C.F.R. 401.607(c)(2). If

you are interested in an extended repayment agreement, please contact this office.

Bankruptcy

If you have filed for bankruptcy and an automatic stay is in effect, you are not subject to offset while

the automatic stay is in effect. Documentation supporting your bankruptcy status, along with a copy

of this notice, must be forwarded to this office at the above address.

We request that you refund this amount in full. If you are unable to make refund of the entire amount at

this time, advise this office immediately so that we may determine if you are eligible for a repayment

schedule. Any repayment schedule (where one is approved) would run from the approval date.

If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding, Medicare financial

obligations will be resolved in accordance with the applicable bankruptcy process. Accordingly, we

request that you immediately notify us about this bankruptcy so that we may coordinate with both the

Centers for Medicare & Medicaid Services and the Department of Justice so as to assure that we handle

your situation properly.

If applicable, we have also initiated a request that your Federal share of Title XIX (Medicaid) payments

be withheld. If this withholding is initiated, it will not be removed until payment in full is received or an

acceptable extended repayment request is received and approved.

Should you have any questions, please contact your overpayment consultant at the following:

&BUSINESS_PURPOSE_1

&CONTRACT_CONTACT_PHONE_NUM_1

&BUSINESS_PURPOSE_2

&CONTRACT_CONTACT_PHONE_NUM_2

&BUSINESS_PURPOSE_3

&CONTRACT_CONTACT_PHONE_NUM_3

&BUSINESS_PURPOSE_4

&CONTRACT_CONTACT_PHONE_NUM_4

&BUSINESS_PURPOSE_5

&CONTRACT_CONTACT_PHONE_NUM_5

We look forward to hearing from you shortly. Sincerely,

Supervisor, Part A Overpayments &CONTRACTOR_NAME

EXHIBIT 7- INTENT TO REFER LETTER - UNFILED COST REPORTS ONLY-

(Rev. 316, Issued: 05-24-19, Effective: 10-01-19, Implementation: 10-07-19)

A. Contractors on HIGLAS shall use the list below for the appropriate system generated letters.

1. (APROVCRUNF3.pdf) Part A Unfiled Cost Report Intent to Refer

B. Contractors not on HIGLAS shall use this letter as your template.

RE: Intent to Refer Letter Provider or Supplier Name: Provider/Supplier Number: &

Overpayment Amount: &HINVOICE_AMOUNT Outstanding

Balance: &DEMAND_AMOUNT

Subject in Bold: Notice of Intent to Refer Unfiled Cost Report Debts to the Department of

Treasury’s Debt Collection Center for Cross Servicing and Offset of Federal Payments

[Insert contractor opening paragraphs concerning the reason for the overpayment, date of

determination and amount due. Refer to previous demand letters or other forms of contact

regarding the debt.]

NOTE: If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding please

follow the instructions found at the end of this letter.

Your unfiled cost report debt to the Medicare Program is delinquent and, by way of this letter, we are

providing notice that your debt may be referred to the Department of Treasury’s Debt Collection Center

(DCC) for Cross Servicing and Offset of Federal Payments. Your debt may be referred under the

provisions of Federal law, Title 31 of the United States Code, § 3720A and the authority of the Debt

Collection Improvement Act of 1996.

The Debt Collection Improvement Act of 1996 (DCIA) requires Federal agencies to refer delinquent debt

to the Department of Treasury and/or a designated Debt Collection Center (DCC) for collection through

cross servicing and/or the Treasury Offset Program. Under the offset program, delinquent Federal debt is

collected through offset of other Federal agency payments you may be entitled to, including the offset of

your income tax return through the Internal Revenue Service (IRS).

The DCC may use various tools to collect the debt, including offset, demand letters, phone calls,

referral to a private collection agency and referral to the Department of Justice for litigation. Other

collection tools available, which may be used, include Federal salary offset and administrative wage

garnishment. If the debt is discharged, it may be reported to the IRS as potential taxable income.

For Individual Debtors Filing a Joint Federal Income Tax Return

The Treasury Offset Program automatically refers debt to the IRS for offset. Your Federal income tax

refund is subject to offset under this program. If you file a joint income tax return, you should contact the

IRS before filing your tax return to determine the steps to be taken to protect the share of the refund, which

may be payable to the non-debtor spouse.

Federal Salary Offset

If the facility ownership is either a sole proprietorship or partnership, your individual salary(s) may be

offset if you are (or become) a federal employee.

Medicaid Offset

As authorized in 42 CFR 447.30, and Section 1914 of the Social Security Act, CMS may instruct the State

Medicaid Agency to offset the Federal share of any Medicaid payments due to you, your agency and/or

related facilities. At that time, the offset shall remain in effect until the Medicare overpayment is paid in

full.

Read the following instructions carefully to determine what action you should take to avoid

referral for cross servicing/offset.

Due Process

You have the right to request an opportunity to inspect and copy records relating to the unfiled cost

report debt. This request must be submitted in writing to the address listed below. You have the right

to present evidence that all or part of your debt is not past due or legally enforceable. In order to

exercise this right, this office must receive a copy of the evidence to support your position, along with a

copy of this letter.

You must submit any evidence that the debt is not owed or legally enforceable within 60 calendar days

of the date of this letter. If, after sixty (60) calendar days from the date of this letter, we have not

received such evidence, your debt, if it is still outstanding and eligible for referral, may be referred to

the Department of Treasury or its designated Debt Collection Center for cross servicing/offset. NOTE:

Unfiled Cost Report debts (including new ones) may be transferred to Treasury for cross

servicing/offset, upon approval from CMS central/regional offices.

Repayment

Your unfiled cost report debt(s) shall not be referred to the Department of Treasury if you submit the

cost report or make the payment in full; otherwise, you will remain legally responsible for any amount

not satisfied through the collection efforts.

Your check or money order for the amount due, made payable to: Medicare

Contractor

Address 000 Street

Anywhere USA 00000-0000

Include a copy of this letter with your payment.

If you cannot make the payment in full, you may be allowed to enter into an extended repayment

agreement.

If you are interested in an extended repayment agreement, please contact this office.

Bankruptcy

If you have filed for bankruptcy and an automatic stay is in effect, you are not subject to offset while the

automatic stay is in effect. You must forward documentation supporting your bankruptcy status, along

with a copy of this notice, to this office at the above address.

If you have any questions concerning this debt, please contact _________________

at __________________________________.

Sincerely,

___________________________

[Signature of Certifying Official]