(Medicare Claims Processing Manual)

On (date of limitation on liability notice), your facility was notified that the services provided to (beneficiarys name) during the period (_________) to (_________) were not covered under Medicare and that you were liable for these items and services.   (Requesters name) has submitted evidence that establishes that he paid your facility (amount paid) for the services received by (beneficiarys name). Because your facility has collected payment from (requesters name) after being determined liable for the se services, 1879(b) of the Act requires that the Medicare program make direct payment (indemnification) to him for this amount, for which (beneficiarys name) is responsible.   A check in the amount of (amount of check) is being sent to (requesters name). This indemnification payment represents an overpayment to your facility and it will be withheld from future Medicare payments due you unless you advise this office that refund of the incorrect amount(s) has been made to (requesters name).   If you do not agree with the amount determined to have been paid you, please contact this office in writing within 15 days of the date of this letter.   Sincerely yours,   Exhibit 2 - Letter to Beneficiary Who Requests Indemnification  (Rev. 1, 10- 01-03)  Dear (Beneficiarys Name):   Your request for refund of improper payment under 1879 of the Social Security Act (the limitation on liability provision) for the noncovered services provided you at (name of provider) from (date) to (date) has been received.   The evidence submitted establishes that, even though you were not responsible for the services you received, you paid (providers name) (amount paid) for the services. Your refund for these payments to (name of provider) has been calculated to be (indemnif ication amount). This figure represents full repayment for the charges you paid.   Your Medicare utilization record will not be charged where noncovered services were provided to you and you were determined not liable.  If you have any questions concerning the matters discussed in this letter or the amount of the check enclosed, please call this office. If you prefer to visit your local social security office, please take this letter with you.   Sincerely yours,   Exhibit 3 - Letter to Someone Other Than Beneficiary Who Requests Indemnification  (Rev. 1, 10- 01-03)  Dear (Persons Name):   Your request for refund of improper payment under Section 1879 of the Social Security Act (limitation of liability provision) for the noncovered services provided (beneficiarys name) at (name of provider) from (date) to (date) has been received.   It was determined that (beneficiarys name) was not liable for the services. The evidence you submitted establishes that you paid (provider) (amount paid) for the services provided (beneficiarys name). Your refund has been calculated to be (indemnification amount). This figure represents full repayment based on the expenses incurred by (beneficiarys name) in the amount of $(amount).   If you have any questions concerning the matters discussed in this letter or the amount of the check enclosed, please call this office. If you prefer, you may visit the local social security office. If you do, take this letter with you.  Sincerely yours,   Exhibit 4 - Letter to Practitioner or Supplier (Noninstitutional Services)  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  Dear ____________________:   Under 1879 of the Social Security Act, a Medicare beneficiary is relieved of the liability for certain categories of noncovered items or services submitted as assigned claims if the beneficiary did not know and could not reasonably be expected to know tha t the items or services would not be covered. Further, the law provides that the practitioner or supplier will be liable for the charges if it is found that he/she knew or could reasonably be expected to know that Medicare would not cover the items or services.   On (date of limitation on liability notification), you were notified that the following items or services provided to (name of beneficiary) were not covered and that you were liable for the charges for these items or services:   Description of Services  Date Provided   (Beneficiary or other person on behalf of beneficiary) has submitted evidence which establishes that he/she paid you $______ for the items or services described above. Since it has been determined that you are liable for the items or services, 1879(b) of the Act requires that the Medicare program  make payment (indemnification) to him/her for this amount. The amount of this payment will be treated as an overpayment to you and appropriate collection action will be taken unless you advise this office that refund has been made to (name of requester).   If you do not agree with the amount that (name of requester(s)) has established he/she paid you, please notify this office.   If we do not hear from you regarding the amount of the payment or that you will make refund directly by_____________ (15 days after date of this notice) payment will be made to (name of requester(s)) and action will be taken to collect the overpayment from  you.  If you disagree with this determination, you may request a redetermination. The bases for such a request are: (1) that the services you provided were reasonable and necessary; (2) that you did not know, and could not reasonably have been expected to know, that Medicare would not pay for the services; or (3) that you notified the beneficiary in writing, before the services were furnished, that Medicare likely would not pay for the services. The request for redetermination must be in writing, and it must be f iled within 120 days of the date you received the initial determination. If you have already received an adverse redetermination, you may request a reconsideration within 180 days of the date you received the redetermination. Our office will assist you if you need help in requesting a  redetermination or a reconsideration. You need not file another request for a redetermination or a reconsideration if you already have taken such action.   Exhibit 5 - Letter to Beneficiary Who Requests Indemnification (Noninstitutional Services)  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  Dear (Beneficiarys name):   Your request for indemnification (i.e., refund of improper payment) under 1879 of the Social Security Act (the limitation on liability provision) for the noncovered services provided you by (physicians/suppliers name) on (date) has been received.   The evidence submitted establishes that you paid (physician/supplier) (amount paid) for the noncovered services. It was determined upon redetermination that you were not liable for these charges. Your refund for these payments to (physician/supplier) has been calculated to be (indemnification amount). This figure represents full repayment for the charges you paid.   If your (physician/supplier) requests an appeal of this claim, it is possible that Medicare might find that your (physician/supplier) also did not know that Medicare would not pay for this service, or that this service should not have been denied. In that case, Medicare would pay your (physician/supplier) for this service. Also, you would be responsible for any deduc tible and coinsurance amounts. If this happens, you will receive a copy of the notice to your (physician/supplier).  Any future items or services of this type provided to you will be your responsibility because this is your notice that Medicare does not cover these services.   If you have further questions concerning this matter, please call this office. If you prefer to visit your social security office, please take this letter with you.   Exhibit 6 - Letter to Someone Other Than Beneficiary Who Requests Indemnification (Noninstitutional Services)  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  Dear (Persons name):   Your request for indemnification (i.e., refund of improper payment) under 1879 of the Social Security Act (limitation on liability provision) for the noncovered services provided (beneficiarys name) by (name of physician/supplier) on (date) has been received.   It was determined upon redetermination that (beneficiarys name) was not liable for the charges.   The evidence establishes that you paid (physician/supplier) (amount paid) for the services provided (beneficiarys name). Your refund has been calculated to be (indemnification amount). This figure represents full repayment for the expenses incurred by (beneficiarys name).   If his/her (physician/supplier) requests an appeal of this claim, it is possible that Medicare might find that the (physician/supplier) also did not know that Medicare would not pay for this service, or that this service should not have been denied. In tha t case, Medicare would pay the (physician/supplier) for this service. Also, (beneficiarys name) would be responsible for any deductible and coinsurance amounts. If this happens, (beneficiarys name) will receive a copy of the notice to his/her (physician/ supplier).   Any future items or services of this type provided to (beneficiarys name) will be his/her responsibility because this is your notice that Medicare does not cover these services.   If you have further questions concerning the matters discussed in this letter or the amount of the check enclosed, please call this office. If you prefer to visit the social security office, please take this letter with you.   Exhibit 7 - Statement of Claimant or Other Person  (Rev. 1, 10- 01-03)  Link to an exhibit of the Form SSA -795,  Statement of Claimant or Other Person,  at:   http://www.ssa.gov/online/ssa -795.pdf .  110 - Contractor Instructions for Application of Limitation On Liability  (Rev. 1, 10- 01-03)  110.1 - Payment Under Limitation on Liability  (Rev. 1, 10- 01-03)  When it is determined during the course of a beneficiarys inpatient stay or during the patients course of home health visits, or during a patients course of treatment from a practitioner, physician or other supplier that the care is not covered but both the beneficiary and the provider of services are entitled to limitation on liability, the Medicare program may make payment for the noncovered services up to the date of notice and, if, for inpatient or home health services, the A/B MAC (A) or (HHH) deter mines that additional time is needed to arrange for post -discharge care, also for a grace period of l day after the date of notice to the provider or to the beneficiary, whichever is earlier. If it is determined that even more time is required in order to arrange post-discharge care, 1 additional grace period day may be paid for. (See 30 and 40 for definition of notice.)   When the provider is given notice as described in 40.1, it is required to advise the beneficiary in writing of the determination on the same date it received the A/B MAC (A) or (HHH) notice. Where the provider fails to give the beneficiary such timely notice, the beneficiary is protected from liability until the beneficiary receives the notice.   For example, if a SNF received the A/B MAC (A)s notice of noncoverage on February 15 but failed to advise the beneficiary until February 19, the beneficiary is protected from liability through February 19 -  the date on which the beneficiary first received  notice. However, the SNF is entitled to program payment only through the date -  February 15 - on which it received notice, and for whatever grace period is allowed thereafter. In a case in which a SNF received the A/B MAC (A)'s notice on February 15 but  failed to give the beneficiary notice until the next day -  February 16 -  the beneficiary and provider, if the A/B MAC (A) determines that additional time is needed to arrange post- discharge care, would be protected from liability under the grace period only for the additional day -  February 16 -  unless it is determined that even more time is required to arrange post-discharge care, in which case 1 additional grace period day may be paid for.   NOTE: The grace period is applicable only where circumstances have permitted program payment under 1879 of the Act, i.e., limitation on liability was applicable both to the beneficiary and the provider of services. Where the A/B MAC (A) or (HH H) concurs with a URCs decision that covered care has ended, any payments made during the grace period after the URCs notice are made under the authority of that statutory provision (1814 of the Act) rather than under 1879.  110.2 - When to Make Limitation on Liability Decisions  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  A - Initial Claims