J1-7 MSPRC Letters 12012010.pdf

Attachment J1.7 11/26/10

Letters

NGHP Letters

Final Settlement Detail Document

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GHP Letters

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Priority Letters

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MARTI Letters

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SMART Letters

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ReMAS Letters

Final Settlement Detail Document

GHP Employer Demand Letter

GHP Insurer Demand Letter

MSPRC Rights and Responsibilities Letter

Primary Payment Notice (PPN)

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NGHP Letters

Final Settlement Detail Document

Beneficiary Name:

Medicare Number:

Date of Incident:

When a beneficiary receives a settlement, judgment, award, or other payment, Medicare is entitled to recover associated payments made by the Medicare program. If certain conditions are met, Medicare reduces its conditional payment to take into account a proportionate share of the costs incurred in resolving the beneficiary’s claim. See 42 C.F.R. 411.37. In general, the recovery demand must be against the individual or entity that received payment, the costs must have been incurred because the matter was disputed, and the costs must be paid by the individual or entity against whom/which

Medicare seeks recovery. There is no proportionate reduction if payment is not in dispute – for example a payment for no-fault insurance.

In order for Medicare to properly calculate the net refund it is due, please supply the information outlined below. This information will also be used to update the beneficiary’s records to show resolution of this matter. If you have a representative, this information should be submitted by your representative on his/her letterhead.

Total Amount of the Settlement: _______________________

Total Amount of Med-Pay or PIP: _______________________

Attorney Fee Amount Paid by the Beneficiary: ___________________ Additional Procurement Expenses Paid by the Beneficiary: _______________________

(Please submit an itemized listing of these expenses)

Date the Case Was Settled: _______/________/_______

This information should be submitted along with a copy of this notice to:

Medicare Secondary Payer Recovery Contractor

<Insert address>

If you have any questions concerning this matter, please call the Medicare Secondary Payer Recovery

Contractor (MSPRC) at 9-999-999-9999 (TTY/TDD: 8-888-888-8888 for the hearing and speech impaired) or you may contact us in writing at the address below. If you contact us in writing, please be sure to include the beneficiary’s name and his/her Medicare health insurance claim number.

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insert name insert address 1 insert address 2 insert city, state, zip code

Date of Incident:

Case Identification Number:

DCN:

Insurer Claim Number:

Dear <insert name>:

Thank you for your letter advising us that you no longer represent <insert beneficiary name> in regards to the above referenced incident.

For us to properly document our records please provide the date your representation ended and the status of the case as of that date. Please send the requested information to the address listed below, or you may fax us the requested information at 7-777-777-7777.

impaired) or you may contact us in writing at the address below. When sending any correspondence please provide the Beneficiary Name, Medicare Health Insurance Claim Number (the number on the

Medicare card) and Case Identification Number (if known). This will allow us to associate the correspondence to the appropriate records.

Sincerely, MSPRC Case Analyst

79001

<insert cc:>

ML003

Beneficiary:

Date of Incident:

Case Identification Number:

Dear <insert name>:

We received your letter dated . You advised us that <insert attorney name> no longer represents you. We have updated our records accordingly.

If you hire a new attorney, please provide a new Proof of Representation and/or Consent to Release to the address below or fax it to 7-777-777-7777. When sending any correspondence please provide the

Beneficiary Name and Medicare Health Insurance Claim Number (the number on the Medicare card).

This will allow us to associate the correspondence to the appropriate records.

Thank you for sharing this information with us. If you have any questions concerning this matter, please call the Medicare Secondary Payer Recovery Contractor (MSPRC) at 9-999-999-9999

(TTY/TDD: 8-888-888-8888 for the hearing and speech impaired) or you may contact us in writing at the address below. When sending any correspondence please provide the Beneficiary Name, Medicare

Health Insurance Claim Number (the number on the Medicare card) and Case Identification Number

(if known). This will allow us to associate the correspondence to the appropriate records.

ML004

Your Client:

Dear insert name:

We received your letter dated concerning your client <insert beneficiaries name>.

Unfortunately, we are not able to confirm Medicare coverage for this individual. Please contact

<insert beneficiary name> and obtain the correct Health Insurance Claim Number (HICN) from their red, white and blue identification card.

The documentation you provided will need to be resubmitted to the address below with the correct

HICN or fax the information to 7-777-777-7777. Please also include the Beneficiary Name and Case

Identification Number (if known). This will allow us to associate the correspondence to the appropriate records.

impaired) or you may contact us in writing at the address below.

insert cc:

ML007

Thank you for your letter dated . We are unable to respond to your request at this time due to lack of information. In order for us to continue processing this case, the following information is needed:

Date of Incident

Description of injuries sustained

Beneficiary Medicare Number (Health Insurance Claim Number)

Settlement Amount

Amount for Attorney fees and case expenses

Itemized listing of the case expenses

Other:

Please mail the requested information to the address below or fax the information to 7-777-777-7777 impaired).

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Date of Incident:

Case Identification Number:

We received your check number <insert check number> in the amount of .

We were unaware this matter had been resolved. If the check referenced above was for medical payment benefits, PIP or no-fault benefits, please advise us if this payment exhausts available benefits.

If not, please provide the policy limit.

If the check was for liability benefits, please provide us with a copy of the signed and dated settlement agreement. Medicare reduces its recovery on contested cases to take into account the cost of procuring the settlement, judgment or award, (42 CFR 411.37). In order for Medicare to apply the reduction, written confirmation of the following information is needed:

o Amount of the settlement o Attorney fees o Itemization of any additional expenses incurred in settling the case

You may mail your letter to the address below or fax the information to 7-777-777-7777.

impaired) or you may contact us in writing at the address below. When sending any correspondence please provide the Beneficiary Name, Medicare Health Insurance Claim Number (the number on the

Medicare card) and Case Identification Number (if known). This will allow us to associate the

<insert address>

Enclosure: Settlement Detail Document reduces its conditional payment to take into account a proportionate share of the costs incurred in resolving the beneficiary’s claim. See 42 C.F.R. 411.37. In general, the recovery demand must be against the individual or entity that received payment, the costs must have been incurred because the matter was disputed, and the costs must be paid by the individual or entity against whom/which resolution of this matter. If you have a representative, this information should be submitted by your

Attorney Fee Amount Paid by the Beneficiary: ___________________ Additional Procurement Expenses Paid by the Beneficiary: _______________________ impaired) or you may contact us in writing at the address below. If you contact us in writing, please be

ML012

<insert Contractor name>

<insert Contractor address 1>

<insert Contractor address 2>

<insert city, state, zip code>

Case Identification Number:

Dear Contractor:

Enclosed with this letter is correspondence and/or a proof of payment by the Medicare Secondary

Payer Recovery Contractor (MSPRC) that relates to a Duplicate Primary Payment (DPP) situation.

According to the Common Working File (CWF), it appears that your organization is the Medicare

Claims Processing Contractor that is responsible for collection the overpayment on this claim(s).

Therefore, your organization is responsible for resolving the DPP situation.

If there is more than one DPP situation indicated, each Medicare Claims Processing Contractor who is responsible for claim(s) will receive this letter and will be responsible for resolving their DPP claim(s).

Contractor (MSPRC) at 9-999-999-9999

Enclosure: Medicare Payment Summary Form and Proof of Payment

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Date of Incident:

Case Identification Number:

The Medicare Secondary Payer Recovery Contractor (MSPRC) has received a letter dated from

<insert correspondent name> in reference to our demand letter dated . We now have information that documents primary payment has already been made for a portion of this debt.

We have recalculated the amount owed on this debt. In doing this recalculation, we eliminated any interest charges associated with the part of the recovery demand amount that was previously paid. Our records show that Choose an item. The amount due through the date of this determination is <insert total amount due including interest>. The principal amount is <insert principal amount> and the interest amount is <insert interest amount>. If this debt remains outstanding after <insert date of the next interest accrual>, the amount due, including interest, will be <insert balance plus one month of interest>. Please be advised that interest will continue accruing every 30 days until the balance is paid in full.

Please refer to our demand letter dated for a summary of your obligations and Medicare’s rights regarding collection of this debt.

impaired) or you may contact us in writing at the address below. When sending any correspondence please provide the Beneficiary Name and Medicare Health Insurance Claim Number (the number on the Medicare card). This will allow us to associate the correspondence to the appropriate records.

Enclosure: Payment Summary Form

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We are in receipt of your letter dated requesting information related to the above referenced case.

A review of the case record indicates that all processing and recovery activity is the responsibility of

<insert HIGLAS Contractor name>, the Medicare claims processing contractor originally assigned to this case. We are forwarding your letter to the appropriate contractor so they may respond to you.

If you have any questions related to this case, please contact <insert Contractor name> at <insert

Contractor address>.

ML016

Insert Name

Insert Address1

Insert Address2

Insert City, State, Zip

Date of Incident:

Case Identification Number:

We are in receipt of your letter dated related to the above referenced case, in which you have claimed bankruptcy/liquidation as your defense.

To consider your defense and properly document your case(s), you must provide us with a copy of your petition for bankruptcy/liquidation within 45 days of receipt of this letter. Please be aware that failure to provide this documentation does not invalidate the debt or alleviate you from your responsibility for repayment of the debt.

impaired) or you may contact us in writing at the address below. When sending any correspondence please provide the Beneficiary Name, Medicare Health Insurance Claim Number (the number on the

Medicare card), and Case Identification Number (if known). This will allow us to associate the

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Date of Incident:

Case Identification Number:

Demand Amount:

Dear insert attorney or other representative name:

This letter acknowledges your client’s request for waiver of recovery of a Medicare overpayment resulting from the <select option> settlement, judgment or award your client received.

In order to help us evaluate your client’s request under §1870(c) of the Social Security Act (42 U.S.C.

1395gg(c)), please complete and return the enclosed Form SSA-632-BK, Request for Waiver of

Overpayment Recovery. Also, please provide an explanation of your client’s reasons for requesting a waiver. Your client is responsible for providing complete documentation substantiating the request, including documentation of procurement costs and out-of-pocket expenses incurred, if any. If your client claims that repaying Medicare will create a financial hardship, you should provide evidence to demonstrate such hardship.

If your client is able to refund a portion of the overpayment, please let us know how much your client is able to repay, with an explanation of why your client is unable to refund the entire amount. Please refer to our letter, in which we explained the criteria that control our determination of whether waiver may be granted.

Any person who makes (or causes to be made) a false statement of representation of material fact in an application or for use in determining a right to payment under the Social Security Act, commits a crime punishable under Federal law and/or State law. In submitting the enclosed SSA-632-BK form and any material documentation, you are deemed to affirm that all information you have given is true.

Please provide the above requested information to the address listed below or fax the information to 7-

777-777-7777. When sending any correspondence please provide the Beneficiary Name and Medicare

Health Insurance Claim Number (the number on the Medicare card). This will allow us to associate the

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Date of Incident:

Case Identification Number

Please note that if we know that you have an attorney or other individual representing you in this matter, we are sending him/her a copy of this letter. If you have an attorney or other representative for this matter and his/her name is not shown as a ―cc‖ at the end of this letter (indicating that he/she is receiving a copy), please contact us immediately. If you have any questions regarding this letter and are represented by an attorney or other person in this matter, you may wish to talk to your representative before contacting us.

This letter acknowledges your request for waiver of recovery of a Medicare overpayment resulting from the <select option> settlement, judgment or award you received. In order to help us evaluate your request under §1870(c) of the Social Security Act (42 U.S.C. 1395gg(c)), please complete and return the enclosed Form SSA-632-BK, Request for Waiver of Overpayment Recovery. Also, please provide an explanation of your reasons for requesting a waiver. You are responsible for providing complete documentation substantiating the request, including documentation of procurement costs and out-of-pocket expenses incurred, if any. If you claim that repaying Medicare will create a financial hardship, you should provide evidence to demonstrate such hardship.

If you are able to refund a portion of the overpayment, please let us know how much you are able to repay, with an explanation of why you are unable to refund the entire amount. Please refer to our letter in which we explained the criteria that control our determination of whether waiver may be granted.

Any person who makes (or causes to be made) a false statement of representation of material fact in an application or for use in determining a right to payment under the Social Security Act, commits a crime punishable under Federal law and/or State law. In submitting the enclosed SSA-632-BK form and any material documentation, you are deemed to affirm that all information you have given is true.

Please provide the above requested information to the address listed below or fax the information to 7-

777-777-7777. When sending any correspondence please provide the Beneficiary Name, Medicare

Health Insurance Claim Number (the number on the Medicare card) and Case Identification Number

(if known). This will allow us to associate the correspondence to the appropriate records.

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Beneficiary: insert name

Medicare Number: insert HICN

Date of Incident:

Case ID: insert ReMAS case ID

DCN: insert DCN matter, we are sending him/her a copy of this letter. If you have an attorney or other representative for this matter and his/her name is not shown as a ―cc‖ at the end of this letter (indicating that he/she is receiving a copy), please contact us immediately. If you have any questions regarding this letter and

We have completed our review of the request for waiver of Medicare’s recovery claim against your liability settlement, judgment, or award. It is our determination that your circumstances do not fall within the criteria used to grant waiver, as set forth in the initial demand letter dated .

Our records show that Choose an item. The amount due through the date of this determination is insert total amount due including interest. The principal amount is insert principal amount and the interest amount is insert interest amount. If this debt remains outstanding after insert date of the next interest accrual, the amount due, including interest, will be insert balance plus one month of interest.

Please be advised that interest will continue accruing every 30 days until the balance is paid in full.

Medicare’s recovery demand letter provided notice that repayment of the debt would not affect your right to appeal (dispute) the debt or to request a waiver of recovery of the debt. That letter also provided notice that interest would be assessed on any debt not repaid in full within 60 days of that date, regardless of whether an appeal or waiver of recovery was requested. Please note that, by regulation, for debts established on or after October 1, 2004, interest is due and payable for each full

30-day period that the debt is not fully liquidated. Interest is accrued monthly from the date of the recovery demand letter (if the debt is not repaid within the time frame specified in that letter) and is added to the balance of any outstanding debt.

This determination is based upon the provisions of Section 1870(c) of the Social Security Act (42

U.S.C. 1395gg(c)), and the Federal regulations found at 42 CFR 405.355-405.356 and 405.358

(including 20 CFR 404.507-509, 404.510a and 404.512, as incorporated by 42 CFR 405.356). These provide, in part, that a beneficiary's overpayment may be waived if the beneficiary is without fault in causing the overpayment and if recovery would either defeat the purpose of the Social Security Act

(including the Medicare Program) or would be against equity and good conscience.

In applying these rules, we found that although you were not at fault in causing the overpayment, Choose an item. For these reasons, we are denying your request that Medicare waive its recovery of this debt.

Use the following paragraph if an attorney does NOT represent the beneficiary, or see below

You received a liability settlement, judgment, or award of $(insert amount). The amount due through the date of this determination is $(insert total amount due included interest).

Use the following paragraph if an attorney does represent the beneficiary

You received a liability settlement, judgment, or award of $(insert amount). The procurement costs in this case, including attorneys fees, were $(insert procurement amount). After allowing $(insert reduction amount) as Medicare's share of procurement costs (see 42 CFR 411.37), the amount due through the date of this determination is $(insert total amoutn due including interest).

Use the following paragraph if an ITR Letter has NOT been sent, or see below

By law, delinquent debts are required to be referred to the Department of Treasury for further collection action. If we do not receive repayment in full within 15 days of the date of this letter, we will send you a separate notice explaining this referral process and the timeframe in which we must be repaid if you wish to avoid this referral process. The amount due through the date of this determination is insert total amount due including interest.

Use the following paragraph if an ITR has already been sent

On [insert ITR letter date], a letter titled ―Notice of Intent to Refer Debt to the Department of

Treasury‖ was issued to you advising that failure to resolve this debt would result in a referral of the debt to the Department of Treasury for further collection action, including the offset of any Federal payment(s) you may be due. If we do not receive repayment in full of the outstanding amount due within 15 days of the date of this letter, we will proceed with our referral action as described in the

Intent to Refer letter. The amount due through the date of this determination is [insert total amount due including interest].

Please make your check or money order payable to Medicare in the amount of and send to the address listed at the end of this letter. Your name and Medicare health insurance claim number should be included on the check. In addition, please enclose a copy of this letter with your check.

Right to Appeal: If you disagree with the decision not to grant a waiver of recovery of this overpayment, you have 120 days from the date you received this letter to request a redetermination (to appeal our waiver of recovery determination). Unless you show us otherwise, we assume you received this letter five (5) days after the date of this letter. Your request for a redetermination must be in writing and must explain why you believe that this determination is in error. Any supporting information or other evidence should be sent with the request for redetermination. The request must be submitted directly to the address above.

All Medicare beneficiaries who do not have an attorney or other representative should be aware that if they decide to exercise their appeal rights and want help with their appeal, they can have a friend, lawyer, or someone else help them. There are groups, such as lawyer referral services and public interest advocacy groups, which can help with finding a lawyer. There are also groups, such as legal aide services, who provide free legal services if certain eligibility requirements are met.

Alert regarding additional settlements, judgments, or awards: Please note that this waiver determination relates to the settlement, judgment, or award referenced in Medicare’s recovery demand letter. If you receive an additional settlement, judgment, or award with respect to the underlying claim, you must notify Medicare. Medicare will then determine if it has a recovery claim against the additional settlement, judgment, or award.

impaired) or you may contact us in writing at the address below. If you contact us in writing, please be sure to include the beneficiary’s name and Medicare health insurance claim number.

ML020

Date of Incident:

matter, we are sending him/her a copy of this letter. If you have an attorney or other representative for this matter and his/her name is not shown as a ―cc‖ at the end of this letter (indicating that he/she is receiving a copy), please contact us immediately. If you have any questions regarding this letter and liability settlement, judgment, or award. It is our determination that your circumstances do not fall within the criteria used to grant waiver, as set forth in the initial demand letter dated . Our records indicate that full payment was received; therefore Medicare considers this debt resolved.

Medicare’s recovery demand letter dated provided notice that repayment of the debt would not affect your right to appeal (dispute) the debt or to request a waiver of recovery of the debt. That letter also provided notice that interest would be assessed on any debt not repaid in full within 60 days of that date, regardless of whether an appeal or waiver of recovery was requested. Please note that, by regulation, for debts established on or after October 1, 2004, interest is due and payable for each full

30-day period that the debt is not fully liquidated. Interest is accrued monthly from the date of the recovery demand letter, if the debt is not repaid within the time frame specified in that letter, and is added to the balance of any outstanding debt.

(including 20 CFR 404.507-509, 404.510a and 404.512, as incorporated by 42 CFR

405.356). These provide, in part, that a beneficiary's overpayment may be waived if the beneficiary is without fault in causing the overpayment and if recovery would either defeat the purpose of the Social

Security Act (including the Medicare Program) or would be against equity and good conscience.

In applying these rules, we found that although you were not at fault in causing the overpayment, after careful review we do not believe that this situation meets the criteria for granting a waiver of the overpayment. For these reasons, we are denying your request that Medicare waive its recovery of this debt.

Right to Appeal: If you disagree with the decision not to grant a waiver of recovery of this overpayment, you have 120 days from the date you received this letter to request a redetermination (to appeal our waiver of recovery determination). Unless you show us otherwise, we assume you received this letter five (5) days after the date of this letter. Your request for a redetermination must be in writing and must explain why you believe that this determination is in error. Any supporting information or other evidence should be sent with the request for redetermination. The request must be submitted directly to the address below.

All Medicare beneficiaries who do not have an attorney or other representative should be aware that if lawyer, or someone else help them. There are groups, such as lawyer referral services and public interest advocacy groups, which can help with finding a lawyer. There are also groups, such as legal aide services, that provide free legal services if certain eligibility requirements are met.

letter. If you receive an additional settlement, judgment, or award with respect to the underlying claim, impaired) or you may contact us in writing at the address below. If you contact us in writing, please be

ML022

Date of Incident:

Case ID: insert ReMAS Case ID matter, we are sending him/her a copy of this letter. If you have an attorney or other representative for this matter and his/her name is not shown as a ―cc‖ at the end of this letter (indicating that he/she is receiving a copy), please contact us immediately. If you have any questions regarding this letter and liability settlement, judgment, or award. The information we received shows that you were without fault in causing the overpayment. In addition, the settlement proceeds were not adequate to repay

Medicare and you retain a fair portion of the settlement. It is our determination that you qualify for a full waiver.

(including 20 CFR 404.507-509, 404.510a and 404.512, as incorporated by 42 CFR 405.356). These provide, in part, that a beneficiary's overpayment may be waived if the beneficiary is without fault in causing the overpayment and if recovery would either defeat the purpose of the Social Security Act (including the Medicare Program) or would be against equity and good conscience. Because you meet these requirements, we are granting a full waiver in respect to the amount owed to Medicare.

Our records indicate Choose an item.; therefore Choose an item.

You may consider our request for repayment in this matter closed. However, please note that this waiver determination relates to the settlement, judgment, or award referenced in Medicare’s recovery demand letter. If you receive an additional settlement, judgment, or award with respect to the underlying claim, you must notify us. We will then determine whether it has a recovery claim against the additional settlement, judgment, or award.

If you have any questions concerning this matter, please call the Medicare Secondary Payer Recovery

Contractor (MSPRC) at 9-999-999-9999 (TTY/TDD: 8-888-888-8888 for the hearing and speech impaired) or you may contact us in writing at the address below. If you contact us in writing, please be

ML024

Date of Incident:

matter, we are sending him/her a copy of this letter. If you have an attorney or other representative for this matter and his/her name is not shown as a ―cc‖ at the end of this letter (indicating that he/she is receiving a copy), please contact us immediately. If you have any questions regarding this letter and fault in causing the overpayment. In addition, the settlement proceeds were not adequate to repay

Medicare and allow you to retain a fair portion of the settlement. It is our determination to partially waive Medicare's recovery claim in the amount of insert amount waived on the principal portion of the debt. We have recalculated the amount owed on this debt. In doing this recalculation, we eliminated any interest charges associated with the part of the recovery demand amount that is being waived.

Our records show that Choose an item. The amount due through the date of this determination is insert total amount due including interest. The principal amount is insert principal amount and the interest amount is insert interest amount. If this debt remains outstanding after insert date of the next interest accrual, the amount due, including interest, will be insert balance plus one month of interest.

Please be advised that interest will continue accruing every 30 days until the balance is paid in full.

affect your right to appeal (dispute) the debt or to request a waiver of recovery of the debt. That letter also provided notice that interest would be assessed on any debt not repaid in full within 60 days of that date, regardless of whether an appeal or waiver of recovery was requested. Please note that, by regulation, for debts established on or after October 1, 2004, interest is due and payable for each full

30-day period that the debt is not fully liquidated. Interest is accrued every 30 days from the date of the recovery demand letter (if the debt is not repaid within the time frame specified in that letter) and is

(including 20 CFR 404.507-509, 404.510a and 404.512, as incorporated by 42 CFR 405.356). These provide, in part, that a beneficiary's overpayment may be waived if the beneficiary is without fault in

Use the following paragraph if an attorney does NOT represent the beneficiary, or see below

You received a liability settlement, judgment, or award of $(insert amount). The amount due through the date of this determination is $(insert total amount due included interest).

Use the following paragraph if an attorney does represent the beneficiary

You received a liability settlement, judgment, or award of $(insert amount). The procurement costs in this case, including attorneys fees, were $(insert procurement amount). After allowing $(insert reduction amount) as Medicare's share of procurement costs (see 42 CFR 411.37), the amount due through the date of this determination is $(insert total amoutn due including interest).

Use the following paragraph if an ITR Letter has NOT been sent, or see below

By law, delinquent debts are required to be referred to the Department of Treasury for further collection action. If we do not receive repayment in full within 15 days of the date of this letter, we will send you a separate notice explaining this referral process and the timeframe in which we must be repaid if you wish to avoid this referral process. The amount due through the date of this determination is insert total amount due including interest.

Use the following paragraph if an ITR has already been sent

On [insert ITR letter date], a letter titled ―Notice of Intent to Refer Debt to the Department of

Treasury‖ was issued to you advising that failure to resolve this debt would result in a referral of the debt to the Department of Treasury for further collection action, including the offset of any Federal payment(s) you may be due. If we do not receive repayment in full of the outstanding amount due within 15 days of the date of this letter, we will proceed with our referral action as described in the

Intent to Refer letter. The amount due through the date of this determination is [insert total amount due including interest].

Please make your check or money order payable to Medicare in the amount of and send to the address listed at the end of this letter. Your name and Medicare health insurance claim number should be included on the check. In addition, please enclose a copy of this letter with your check.

Right to Appeal: If you disagree with this determination granting a partial waiver of recovery of this overpayment, you have 120 days from the date you received this letter to request a redetermination (to appeal our waiver of recovery determination). Unless you show us otherwise, we assume you received this letter five (5) days after the date of this letter. Your request for a redetermination must be in writing and must explain why you believe that this determination is in error. Any supporting information or other evidence should be furnished with the request for redetermination. The request must be submitted directly to the address below.

All Medicare beneficiaries who do not have an attorney or other representative should be aware that if lawyer, or someone else help them. There are groups, such as lawyer referral services and public interest advocacy groups, which can help with finding a lawyer. There are also groups, such as legal letter. If you receive an additional settlement, judgment, or award with respect to the underlying claim, impaired) or you may contact us in writing at the address below. If you contact us in writing, please be

ML025

Date of Incident:

matter, we are sending him/her a copy of this letter. If you have an attorney or other representative for this matter and his/her name is not shown as a ―cc‖ at the end of this letter (indicating that he/she is receiving a copy), please contact us immediately. If you have any questions regarding this letter and fault in causing the overpayment. In addition, the settlement proceeds were not adequate to repay

Medicare and allow you to retain a fair portion of the settlement. It is our determination to partially waive Medicare's recovery claim in the amount of insert amount waived on the principal portion of the debt. We have recalculated the amount owed on this debt. In doing this recalculation, we eliminated any interest charges associated with the part of the recovery demand amount that is being waived. Our records indicate that full payment was received; therefore Medicare considers this debt resolved. If a refund is due it will be sent under separate cover.

(including 20 CFR 404.507-509, 404.510a and 404.512, as incorporated by 42 CFR 405.356). These provide, in part, that a beneficiary's overpayment may be waived if the beneficiary is without fault in affect your right to appeal (dispute) the debt or to request a waiver of recovery of the debt. That letter also provided notice that interest would be assessed on any debt not repaid in full within 60 days of that date, regardless of whether an appeal or waiver of recovery was requested. Please note that, by regulation, for debts established on or after October 1, 2004, interest is due and payable for each full

30-day period that the debt is not fully liquidated. Interest is accrued monthly from the date of the recovery demand letter (if the debt is not repaid within the time frame specified in that letter) and is

Right to Appeal: If you disagree with this determination granting a partial waiver of recovery of this overpayment, you have 120 days from the date you received this letter to request a redetermination (to appeal our waiver of recovery determination). Unless you show us otherwise, we assume you received this letter five (5) days after the date of this letter. Your request for a redetermination must be in writing and must explain why you believe that this determination is in error. Any supporting information or other evidence should be furnished with the request for redetermination. The request must be submitted directly to the address below.

All Medicare beneficiaries who do not have an attorney or other representative should be aware that if lawyer, or someone else help them. There are groups, such as lawyer referral services and public interest advocacy groups, which can help with finding a lawyer. There are also groups, such as legal letter. If you receive an additional settlement, judgment, or award with respect to the underlying claim, impaired) or you may contact us in writing at the address below. If you contact us in writing, please be

ML035

Date of Incident:

On we sent you a conditional payment letter that detailed Medicare’s interest in the above referenced matter. The letter documented Medicare’s interest to be .

You contacted us and are disputing whether certain claim(s) are related to the case. The claims in question are attached.

For us to consider removing the claim(s) from Medicare’s lien amount, we require additional documentation. Please provide us with a written explanation as to why you feel these claims are not related to the case. Please supply any medical records that support your position. We also request copies of ―claims pleading‖ documents, if they exist, that would help us understand more clearly what is being claimed in the case.

Please provide the above requested information to the address identified below or fax the information to 7-777-777-7777. When sending any correspondence please provide the Beneficiary Name and

Medicare Health Insurance Claim Number (the number on the Medicare card). This will allow us to associate the correspondence to the appropriate records.

We thank you for your assistance in this matter. Upon receipt of the requested information we will further review the case and let you know if any of the claim(s) will be removed from Medicare’s lien amount.

Enclosure: Payment Summary Form

ML036

Date of Incident:

This is in response to your letter dated . In your letter, you inquired about Medicare waiving all or a portion of its interest in the above referenced case.

Waiver of Medicare’s interest cannot be considered at this time because no overpayment currently exists. An overpayment exists only after the case has settled and Medicare has issued a formal demand for repayment. The formal demand for repayment letter that we send outlines the actions you should take to request waiver.

When the case does settle, please complete the attached ―Final Settlement Detail Document‖ and return it to us. Upon receipt of the fully completed form, we will perform a final search of Medicare claims history and issue the formal demand for repayment letter.

impaired) or you may contact us in writing at the address below. When sending any correspondence please provide the Beneficiary Name and Medicare Health Insurance Claim Number (the number on the Medicare card). This will allow us to associate the correspondence to the appropriate records.

Enclosure: Final Settlement Detail Document reduces its conditional payment to take into account a proportionate share of the costs incurred in resolving the beneficiary’s claim. See 42 C.F.R. 411.37. In general, the recovery demand must be against the individual or entity that received payment, the costs must have been incurred because the matter was disputed, and the costs must be paid by the individual or entity against whom/which resolution of this matter. If you have a representative, this information should be submitted by your

Attorney Fee Amount Paid by the Beneficiary: ___________________ Additional Procurement Expenses Paid by the Beneficiary: _______________________ impaired) or you may contact us in writing at the address below. If you contact us in writing, please be

ML040

Please note that, if we know you have an attorney or individual representing you in this matter, we are sending him/her a copy of this letter. If you have an attorney or other representative for this matter and his/her name is not shown as a ―cc‖ at the end of this letter (indicating that he/she is receiving a copy), please contact us immediately. If you have any questions regarding this letter and are represented by an attorney or other person in this matter you may wish to talk to your representative before contacting us.

This letter follows a previous letter notifying you/your attorney of Medicare’s priority right to recovery as defined under the Medicare Secondary Payer provisions. Because you were involved in an automobile, slip and fall, medical malpractice, or some other type of liability claim, the medical expenses are subject to reimbursement to Medicare from proceeds received pursuant to third party liability settlements, awards, judgments, or recovery.

However, we request that you/your attorney refrain from sending any monies to Medicare prior to submission of settlement information and receipt of a demand/recovery calculation letter from our office. This will eliminate underpayments, overpayments, and/or associated delays.

Currently, Medicare has paid in conditional payments related to your claim. Attached you/your attorney will find a listing of claims that comprise this total. Please take a look at this listing and let us know if you/your attorney disagree with the inclusion of any claim in whole or in part and explain the reasons why you/your attorney disagree(s).

Please be advised that we are still investigating this case file to obtain any other outstanding Medicare conditional payments. Therefore, the enclosed listing of current conditional payments (including a response of zero amount) is not a final listing and will need to be updated once we receive final settlement information from you. It would be in your best interest to keep Medicare’s payments and the statutory obligations to satisfy Medicare in mind when the final dollar amount is negotiated and accepted in resolution of this claim with the third party.

If the case has settled, please furnish our office with a copy of:

1) The settlement agreement from the third party payer showing the total amount the settlement, signed and dated, AND

2) Your closing statement reflecting the actual amount of the attorney’s fees and cost

(excluding medical bills) impaired) or you may contact us in writing at the address below. If you contact us in writing, please be

MSPRC insert title insert site identifier

ML041

RE: Name:

HIC#:

Date of Incident:

Debt Identification No:

matter, we are sending him/her a copy of this letter. If you have an attorney or other representative for this matter and his/her name is not shown as a ―cc‖ at the end of this letter (indicating that he/she is receiving a copy), please contact us immediately. If you have any questions regarding this letter and are represented by an attorney or other individual in this matter, you may wish to talk to your

We are writing to you because we recently learned that you have made a liability claim relating to an illness, injury, or incident occurring on or about and obtained a recovery. We have determined that you are required to repay the Medicare program for the cost of medical care it paid relating to your liability recovery. (The term ―recovery‖ includes a settlement, judgment, award, or any other type of recovery.)

We hope that you will find the answers to some of the questions you may have about this letter below.

Parts I and II of this letter explain the federal law that requires you to pay Medicare back and the way we determined the amount you are required to repay. We have provided instructions for repaying

Medicare in Part III of this letter. You have the right to appeal our determination if you disagree with it, and you also have the right to request that the Medicare program waive recovery of the amount you owe in full or in part. Instructions for requesting the waiver of recovery and appeal are provided in

Part IV of this letter. Part V of this letter explains the interest charges that apply if you do not repay

Medicare within sixty (60) days from the date of this letter and tells you about certain actions Medicare may decide to take if you fail to repay the amount you owe. Finally, Part VI identifies whom you should contact if you have questions about this letter.

I. Why am I required to repay Medicare?

You are required to repay Medicare because Medicare paid for medical care you received related to your liability recovery. The Medicare Secondary Payer (MSP) law allows Medicare to pay for medical care received by a Medicare beneficiary who has or may have a liability claim. However, the law also requires Medicare to recover those payments if payment of a liability settlement, judgment, recovery, or award has been or could be made. Congress passed the MSP law because it wanted to make sure that the Medicare Trust Funds would have enough money to pay for medical care that beneficiaries may need in the future. Congress decided that, if a liability recovery was available to pay for a

Medicare beneficiary’s medical care, then that money should be used to pay for the care and any amounts already paid by Medicare should be refunded to the Medicare Trust Funds.

If you would like to read the MSP law, you can find it in Title 42 of the United States Code, Section

1395y(b)(2). You can also find the regulations that explain how the Medicare program recovers amounts it is owed under the MSP law in Title 42 of the Code of Federal Regulations, beginning at

Section 411.20. You can also learn more about how the MSP law works by contacting your local

Social Security office or by visiting www.medicare.gov

II. How did Medicare decide how much money I owe?

The Medicare program paid for medical care related to your liability recovery. We have enclosed a list of the payments Medicare made related to your recovery with this letter. The Medicare program generally reduces the amount a Medicare beneficiary is required to repay to take into account the costs (such as attorney’s fees) paid by the beneficiary to obtain his or her liability recovery. You can find the formula we use to decide how much the amount of this reduction should be at 42 C.F.R., sub-section 411.37. We have applied the formula and determined that the amount you owe Medicare is .

This letter related only to money paid from your current recovery. If, in the future, you receive additional money from this liability recovery, or any other liability recovery, you must let us know.

III. What do I need to do to repay Medicare the amount I owe?

You must repay Medicare within sixty (60) days of the date of this letter . Please send a check or money order for insert demand amount, made payable to Medicare, to us at the address listed at the end of this letter. Please make sure to include your name and Medicare number on the check or money order and include a copy of this letter with your payment.

The amount requested in this letter may not include payments received prior to the issuance of this demand letter dated . Upon issuing a check, please deduct previous payments made to the

MSPRC for the above referenced debt.

IV. What rights do I have if I disagree with the amount this letter says I owe or think that I should not have to repay Medicare for some other reason?

Rights to Request a Waiver—You have the right to request that the Medicare program waive recovery of the amount you owe in full or in part. Your right to request a waiver is separate from your right to appeal our determination, and you may request both a waiver and an appeal at the same time. The

Medicare program may waive recovery of the amount you owe if you can show that you meet both of the following conditions:

http://www.medicare.gov/

1. This overpayment (for purposes of requesting waiver of recovery, the amount you owe is considered an overpayment) was not your fault, because the information you gave us with your claims for Medicare benefits was correct and complete as far as you knew; and when the Medicare payment was made, you thought that it was the right payment;

AND

2. Paying back this money would cause financial hardship or would be unfair for some other reason.

If you believe that both of these conditions apply to you, you should send us a letter that explains why you think you should receive a waiver of the amount you owe. If you request a waiver, we will send you a form asking for more specific information about your income, assets, expenses, and the reasons why you believe you should receive a waiver. If we are unable to grant your request for a waiver, we will send you a letter that explains the reason(s) for our decision and the steps you will needs to follow to appeal that decision if it is less than fully favorable to you.

Right to Appeal- You also have the right to appeal our determination if you disagree that you owe

Medicare as explained in Part I of this letter, or if you disagree with the amount that you owe Medicare as explained in Part II of this letter. To file an appeal, you should send us a letter explaining why you think the amount you owe Medicare is incorrect and /or any reason(s) why you disagree with our determination.