TN 1 (03-05)

HI 02201.015 Medicare Appeal Requests and Refunds

A. GENERAL

When an individual or his/her authorized representative receives a notice from SSA that a Medicare overpayment will be withheld from title II benefits and protests the withholding, the protest applies only to the deduction from his/her title II benefits. It does not apply to the Medicare overpayment because the Medicare contractor has determined that the overpayment must be recovered.

B. PROCEDURE – FIELD OFFICE (FO)

If the FO receives an appeal and/or waiver request, do not process; stop recovery. Immediately send the request to the processing center (PC). (See HI 02201.015D. for necessary forms.) Only the PC will know whether or not the Medicare contractor has already made a waiver decision.

If a person asks for advice about returning an erroneous Medicare payment, tell the person to call their local Medicare contractor about the erroneous payment before returning it. (See GN 02403.040 for processing returned Medicare contractor checks and/or Medicare overpayment refunds received in the PC.)

C. PROCEDURE – PC

If the Medicare contractor has denied an initial waiver request, process the overpayment in accordance with current operating procedures. Medicare has given the individual waiver and appeal rights.

If the individual has not requested waiver with the contractor but files a waiver request with SSA, return the overpayment package to the appropriate contractor for processing.

D. LIST OF FORMS TO USE WHEN A BENEFICIARY FILES WAIVER/APPEAL

When an individual or his/her representative comes to SSA to request a waiver and/or an appeal of the Medicare overpayment withholding, complete one of the following forms, depending on the request:

  • Waiver - Form 632-BK (Request for Waiver of Overpayment and Recovery of Change in Repayment Rate)

  • Appeal of Withholding - SSA-795 (Statement of Claimant or Other Person) (Since the rate of the withholding is not an initial determination, do not use the SSA-561 (Request for Reconsideration) or HA-501 (Request for Hearing).)

NOTE: If a Medicare contractor, CMS Regional Office or the administrative law judge has previously denied waiver, cross program adjustment is mandatory.

E. PROCEDURE – STOP WITHHOLDING

If this is an initial waiver request:

  • Stop withholding as shown in SM 00610.790B.; and

  • Forward the request to the referring agency (CMS Central Office, CMS RO or the Medicare contractor) for a wavier determination.

F. EXHIBITS

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:

  1. The liable individual was without fault with respect to the overpayment, and

  2. 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.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0602201015
HI 02201.015 - Medicare Appeal Requests and Refunds - 03/10/2005
Batch run: 01/27/2009
Rev:03/10/2005