EXHIBIT A
BENEFICIARY OVERPAYMENT REFERRAL NOTICE
(CONTRACTOR COMPLETES ENTIRE NOTICE)
DATE:
MEMORANDUM TO: (1) NEPSC (2)
MATPSC (3) SEPSC (4) GLPSC
(Circle One) (5) WNPSC (6)
MAMPSC (7)
OIO RRB
ATTENTION: Benefit Authorizer: Attached is an uncollectible Medicare beneficiary overpayment. If the beneficiary
is not in your jurisdiction, please forward to the correct office.
SUBJECT: MEDICARE
BENEFICIARY OVERPAYMENT
Health Insurance Claim No.
Beneficiary Name:
Address:
Overpayment Amount:
Total HI: Total SMI:
Medicare Contractor:
Contractor Number:
Contact Person:
Address
Contact Person/Telephone Number (area code)
Fax Number:
Please recover this Medicare overpayment
per POMS (see Note below).
A description of the overpayment, cause and amount are included in the attached overpayment
case. This information is also summarized in the overpayment transmittal letter.
The attached “Return Notice,” should be completed and returned to the contractor when the overpayment has been
recovered or when the case is considered closed by the PSC.
NOTE: The Centers for Medicare and Medicaid Services has authorized Medicare contractors
to forward beneficiary overpayment cases to the PSC for recovery of the overpayment
by offset against beneficiary monthly benefits. The recovery should be handled in
accordance with HI 02201.001-HI 02201.015.
-
•
This notice/exhibit will be used for transmitting recovery action(s).
-
•
If waiver is later requested or the overpayment decision is protested, return to the
above contractor.
EXHIBIT B
BENEFICIARY OVERPAYMENT RETURN NOTICE
{Fill-in by PSC} DATE:
{Fill-in by To
(Medicare Contractor):
Medicare Address:
Contractor}
FAX
Number
Please fill in the following information as applicable and return to the above address
when the overpayment is recovered or it is considered to be closed:
SUBJECT: MEDICARE OVERPAYMENT
FROM PROGRAM SERVICE CENTER: (Indicate with check mark)
{Fill-in NEPSC (PC1) MATPSC (PC2) SEPSC (PC3) GLPSC (PC4)
by PSC} WNPSC (PC5) MAMPSC (PC6) OIO (PC7) RRB
{Fill-in NAME OF BENEFICIARY:
by PSC}
BENEFICIARY HEALTH INSURANCE CLAIM NO.
{Fill-in AMOUNT OF OVERPAYMENT COLLECTED:
by PSC}
TOTAL DOLLAR AMOUNT CREDITED TO TRUST FUND:
HI: SMI:
NOTE: Monies should be applied to Part A (HI) debt first.
{Fill-in SERVICE DATE(S):
by PSC}
CONTRACTOR NUMBER:
PSC
CONTACT PERSON
TELEPHONE
NUMBER (AREA CODE)
Comments:
EXHIBIT C
WAIVER DETERMINATION
Contractor Name:
Service Dates:
Amount of Overpayment:
Beneficiary HIC Number:
Beneficiary SSN Number:
Section 1870(c) of the Social Security Act (SSA) provides that there shall be no adjustment
or recovery of an overpayment of health insurance benefits from a Medicare beneficiary
nor from persons entitled to survivor's benefits on the beneficiary's earnings record
when:
-
(a)
The liable individual was without fault with respect to the overpayment, and
-
(b)
Adjustment or recovery would either:
-
(1)
Be against equity and good conscience, or
-
(2)
Defeat the purpose of Title II/Title XVIII of the SSA.
Waiver of recovery is denied because of the following
reason(s)
Notification of Waiver Decision to liable individual:
Name:
Address:
Waiver Determination Made By:
Date of Signature:
Determination Approved By:
Date of Signature:
EXHIBIT D
BENEFICIARY OVERPAYMENT REFERRAL FOLLOW-UP
NOTICE
(CONTRACTOR COMPLETES ENTIRE NOTICE)
DATE:
MEMORANDUM TO: (1) NEPSC (2)
MATPSC (3) SEPSC (4)
GLPSC
(Circle One) (5)
WNPSC (6) MAMPSC (7)
OIO RRB
ATTENTION: Benefit Authorizer: Attached is a copy of
our previously resubmitted Beneficiary Overpayment Referral Notice
(Exhibit A), dated: .
ATTENTION: Benefit Authorizer: Attached is a copy of
your Beneficiary Overpayment Return Notice (Exhibit B), dated:
SUBJECT: Health
Insurance Claim No.
Beneficiary
Name:
Original
Overpayment Amount:
Original
Referral Date:
Medicare
Contractor:
Contractor
Number:
Contact
Person:
Address:
Contact
Person/Telephone Number (area code)
Fax
Number: (Area Code)
SSA
provide the current Status of the Medicare overpayment:
SSA
Contact Person: Date:
NOTE: This Follow-Up Notice must be used in situations
where the Medicare contractor has not received any information from
the SSA/PSC after 1 year concerning the recoupment of the Medicare
overpayment and in situations where the beneficiary is no longer
in a pay status.