CMS Pub. 100-06, ch. 4, § 70.17.3

The Treasury returns debts with this status code because the dispute response was not received timely.

The contractor shall research and resolve the debts in a RX status that have a combined principal and

interest balance greater than or equal to $25 within 30 business days in order to determine the current

status of the debts. No further action is necessary if the debts are already in a recalled status. The

contractors shall add a comment on the HIGLAS comment screen reflecting any action taken, the date of

the RTA report in which the debts appear on and the financial statement reporting quarter in which the

debts were resolved.

RX debts that have a combined principal and interest balance of less than $25

• Contractor Utilizing HIGLAS shall allow HIGLAS to systematically change the status code

to‘DR-RTN-CS’(Debt Returned from Cross-Servicing) which will allow the debt to be identified

and written off by the HIGLAS Auto Write-Off Program.

• Contractors NOT Utilizing HIGLAS shall submit these debts for close-out.

If the debts are still valid and eligible for referral to Treasury, the contractors shall re-refer the debts to

Treasury, even if a response to the disputes were previously submitted to Treasury. The contractors shall

not issue a second Intent to Refer (ITR) letter.

70.17.4 - Debts RTA by Treasury as a Miscellaneous Dispute, a Manual RTA, Complaint or as

Recall Approved (RD) (Rev. 11787; Issued:01-19-23; Effective:

04-21-23; Implementation:04-21-23)

The contractor shall research and resolve debts in a RD RTA status code greater than or equal to $25 and

within 30 calendar days update HIGLAS or its internal system with the final disposition of the debts. If

any debts are still valid and eligible for referral to Treasury, the contractors shall change the status code of

the debts from RD to R-DCS (Debt Resubmitted to Cross-Servicing) to be resubmitted to Treasury. The

contractors shall not issue a second Intent to Refer (ITR) letter for the debts.

RD debts that have a combined principal and interest balance of less than $25

• Contractor Utilizing HIGLAS shall allow HIGLAS to systematically change the status code to

‘DR-RTN-CS’ (Debt Returned from Cross-Servicing) which will allow the debt to be identified

and written off by the HIGLAS Auto Write-Off Program.

• Contractors NOT Utilizing HIGLAS shall submit these debts for close-out.

70.17.5 - Debts RTA by Treasury as Paid in Full (RP), Satisfied Payment Agreement (RP) or

Satisfied Compromise (RC) (Rev. 11787; Issued:01-19-23; Effective:

04-21-23; Implementation:04-21-23)

• If a debt is returned to agency (RTA) as paid in full (RP), satisfied payment agreement (RP), or

compromise (RC) and a principal balance less than $100 remains after the receipt has been

applied, contractors not utilizing HIGLAS shall adjust down the remaining balance. HIGLAS

shall systematically adjust down these balances to $0.00 for contractors utilizing HIGLAS.

• If a debt is returned to agency (RTA) as paid in full (RP) or satisfied payment agreement (RP),

and a principal balance greater than or equal to $100 remains after the receipt has been applied,

the contractor shall research all activity on the debt to determine if the receipts were

appropriately applied and take any action, if needed. If all receipts were applied appropriately,

the contractor shall then adjust down the remaining balance to $0.00.

• If a debt is returned to agency (RTA) as satisfied compromise (RC) the contractor shall research

all activity on the debt to determine if the receipts were appropriately applied and take any

action, if needed. The contractor shall adjust down the balance to $0.00 using the appropriate

adjustment/write-off code.

If it is determined a refund is valid, the contractors shall follow procedures for applying excess collections

and update HIGLAS or their internal systems to reflect any refund given (see CMS Pub. 100-06, chapter

4, section 70.14.8).

Exhibit 1- Intent to Refer (ITR) Letter

(Rev. 294, Issued: 10-06-17, Effective: 07-03-17, Implementation: 07-03-17)

Intent to Refer Letter

Background

The DCIA requires Federal agencies to refer debt that is 120 days delinquent to the Department of

Treasury or a Treasury designated Debt Collection Center for cross servicing.

Prior to debt transfer, the DCIA requires agencies to inform the debtor of the agency’s intent to refer the

debt, and to provide debtor information regarding the referral process.

Attached are specific paragraphs that explain the process and debtor rights. These paragraphs shall be

included in the intent to refer letter sent to the debtor.

Medicare contractors should use their own language in the opening paragraphs to explain the reason for

the overpayment and the current balance, including interest accrued and the interest rate.

Subject in Bold: 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

Contractor opening paragraphs concerning the reason for the overpayment, date of determination and

amount due. May refer to previous demand letters or other forms of contact regarding the debt.

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. Your debt will be referred under provisions of Federal law, title 31 of the

United States Code, Section 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

debts 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

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 to which you are entitled.

The Debt Collection Center will 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 will continue to accrue on the debt and you will 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 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.

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 at 42 CFR 447.30, (Subsection 1885 of the Social Security Act), CMS may instruct the

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

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

full.

Please read the following instructions carefully to determine what action you may 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 days of the date of this letter. If,

after sixty days from the date of this letter, we have not received such evidence, your debt, if it is still

outstanding and eligible for referral, will be referred to the Department of Treasury or its designated Debt

Collection Center for cross servicing/offset.

Repayment

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

amount of $____________owed to the Medicare Program as of _____________ includes interest accrued

through _____________. (Note: Medicare contractors may alter this sentence to read: The past due

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

interest. This sentence may be omitted for debts that do not accrue 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:

Medicare

Contractor Address

000 Street

Anywhere, USA 00000-0000.

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 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.

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

at ________________.

Sincerely,

____________________

Signature of Certifying Official

Official Position

Exhibit 5

(Rev. 315, Issued: 05-17-19, Effective: 06-18- 19, Implementation: 06-18-19)

The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare

identification number. For purposes of this manual, Medicare beneficiary identifier references both the

Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new

Medicare card transition period and after for certain business areas that will continue to use the HICN as

part of their processes.

Treasury Cross-Servicing Dispute Resolution

DMS Request Date: Total Number of Pages: _____

SBU

FedDebt Case ID.: Principal Amt: $

Creditor Agency Debt ID: PCA Code:

Debtor:

Program: For CMS Use Only:

Creditor Agency Contact Name: Medicare beneficiary identifier:

Creditor Agency Contact Phone: Beneficiary Name:

Creditor Agency Facsimile:

Dispute Number:

Dispute request reason: Miscellaneous Dispute

Additional comments:

If you have any questions regarding the dispute, please call Valencia Thompson at 205-912-6327.

Creditor Agency must return response to Bosch Stanley via facsimile 205-912-6374 with 60 days of

request date.

Creditor Agency (CA) Dispute Resolution Section:

Please indicate a response by checking one of the following reasons: Please attach supporting

documentation.

DAIC ___ CA agrees. Debt amount is incorrect. Requires financial adjustment.

DACC ___ CA disagrees. Debt amount is correct. Continue collection efforts.

MDAA ___ CA agrees. Miscellaneous dispute, stop collection activity.

MDFF ___ CA agrees. Miscellaneous dispute. Requires financial adjustment, continue

collection efforts.

MDDD ___ CA disagrees. Miscellaneous dispute. Continue collection efforts.

VDWD ___ CA agrees. Wrong debtor, stop collection activity.

VDRD ___ CA disagrees. This is not the wrong debtor, continue collection efforts.

VDPP ___ CA agrees. Previously paid, stop collection activity.

VDNP ___ CA disagrees. Not previously paid, continue collection efforts.

VDPR ___ CA agrees. Previously resolved, stop collection activity.

VDNR ___ CA disagrees. Not previously resolved, continue collection efforts.

Financial Adjustment Information (To Be Completed By Creditor Agency):

Principal Amount $_______________

Interest Amount $_______________

Penalty Amount $_______________

Admin Cost Amount $_______________

Total Balance Owed $_______________

Please check one of the following:

□ Adjustment reflects the total balance currently owed by the debtor, and has been made by our

Agency.

□ Adjustment has not been made in FedDebt by the Agency, and should be made by DMS.

Creditor Agency Response Date: __________ Creditor Agency Response Contact:

__________________

Additional Comments By Creditor Agency:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________