SAMPLE Demand Letter
INSERT RAC LOGO
Region __ Recovery Audit Contractor (RAC)
RAC Point of Contact
City, State Zip
Re: Provider Name #123456789
Dear Medicare Provider,
The Centers for Medicare & Medicaid Services (CMS) has retained (name of RAC) ______________ to
carry out the Recovery Audit Contracting (RAC) program in the State of ________. The RAC program
is mandated by Congress aimed at identifying Medicare improper payments.
This letter is to notify you that Medicare has made an overpayment to you for the amount of $_______.
A brief description of the claims associated with this overpayment can be found on the "Overpayment
Report" page. Our review results letter dated xx/xx/xxxx provided the detailed reason(s) for the
overpayment determination. In order to correct this overpayment, please refund $_______by
Our request for additional medical documentation, detailed in a letter dated xx/xx/xxxx, constituted
reopening under §1869(b) (1) (G) of the Social Security Act and 42 CFR 405.980(a) (1). Our good cause
to reopen the claim, if required by 42 CFR 405.980(b) (2), was described in the letter as well.
Please make the check payable to Medicare and send it with a copy of this letter to the following
P.O. Box 9999
City, State Zip
If your local claims processing contractor offers an immediate offset option contact (name of
NOTE: If the overpayment is for services that are not medically reasonable and necessary per Medicare
standards, and you collected the amount of the overpayment from the beneficiary, the beneficiary has the
right to request payment from Medicare. Any such indemnification will be recovered from you.
As you review the overpayment, below is some important information and key timeframes (15, 30, 40 and
120 days) to consider:
• Rebuttal Process: