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Home My WebLink About256049 03/01/16 �,�\ CITY OF CARMEL, INDIANA VENDOR: 369203 ONE CIVIC SQUARE WISCONSIN PHYSICIANS SERVICE INS btlECK AMOUNT: $*******326.1 1* :� ?� CARMEL, INDIANA 46032 PO BOX 8811 CHECK NUMBER: 256049 '.y;�TON�O` MARION IL 62959 CHECK DATE: 03/01/16 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 2/15/2016 326.11 OTHER EXPENSES VOUCHER NO. WARRANT NO. ALLOWED 20 ��u�� Z�s. Q • IN SUM OF $ ON ACCOUNT OF APPROPRIATION FOR Board Members PO#or DEPT.# INVOICE NO. ACCT#/TITLE AMOUNT I hereby certify that the attached invoice(s), or '3ao�4 bill(s) is (are) true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except FEB 1 0 2016 20 Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund i J-4 IIS. I;f CITY O 1�RMEL JAMES BRmNARD, MAYOR February 8, 2016 WISCONSIN PHYSICIANS SERVICES INS_ . CORP P.O. Box 8811 MARION, IL 62959 RE : WPS MEDICARE LETTER# 19994075 Account#20152061 :1 Dear MEDICARE REFUND DEPARTMENT: We have received your letter for FRANCES OLAND. Reason for overpayment: Claim Correction. Refund $326.11 to be issued to Wisconsin Physicians Service Insurance Corporation. If you have any questions, please feel free to contact me at(3 17) 571-2604. Sincerely, /ll 01 -//��-, , Michelle T. Harrington EMS Billing Administrator CARMEL FIRE DEPARTMENT STEVEN A. COUTS HEADQUARTERS Two Cmc SQUARE, CARMEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615 MEDICARE Part B Letter Number: 19994075 Date: 01/21/2016 - CITY OF CARMEL 2 CIVIC SQUARE CARMEL, IN 460322584 FIRST REQUEST RE .- MMA 935 =Overpayment-Amount Provider Name: CITY OF CARMEL Provider Number: 1154325579 Outstanding Balance: $326.11 Dear Sir/Madam, This is to inform you that you have received a Medicare payment in error which has resulted in an overpayment of $326.11. This amount is subject to Section 935(f)(2) of the Medicare Modernization Act (MMA) (Section 1893(f)(2) of the Social Security Act), Limitation on Recoupment. The purpose of our letter is to request that this amount be repaid to our office. The attached listing explains how this happened. Why you are responsible: You are responsible for being aware of correct claim filing procedures. In this situation, you billed and/or received payment for services you should have known you were not entitled to. Therefore, you are not without fault and are responsible for repaying the overpayment amount. It you dispute this determination please follow the appropriate appeals process listed below. Applicable authorities: Section 1870(b)(c) of the Social Security Act; Subsections 405.350 - 405.359 of Title 42 CFR, Subsections 404.E)'06 - 404.509, 404.510a and 404.5 12 of Title 20 of the United States Code of Federal Regulations and 20 CFR. What you should do: Please return the overpaid amount to us by 02/19/2016 and no interest charge will be assessed. We request that you refund this amount in full. If you are unable to make refund of the entire amount at this time, advise this office immediately so that we may determine if you are eligible Wisconsin Physicians Service Ins. Corp. P.O. Box 1787,Madison,WI 53701 www.W'psmedicare.com Page 2 Date : 01/21/2016 Letter Number : 19994075 v for a repayment plan. Any repayment plan (where one is approved) would run from the date of this letter. Make the check payable to Medicare Part B and send it with a copy of this letter to: Wisconsin Physicians Service Ins. Corp. P.O. Box 8811 Marion, IL 62959 You may elect to have your overpayment(s) repaid through the immediate recoupment process and avoid paying by check or waiting for the standard recoupment process that begins on day 41 from date of the initial demand letter. A request for immediate recoupment must be received in writing no later than the 16th day from the date of initial demand letter. You must specify whether you are submitting: 1. A one-time request for the current overpayment and all future overpayments, or 2. A request for the current overpayment addressed in this demand letter only. This process-is voluntary and for your convenience. Your request must specifically state you understand you are waiving potential receipt of interest payment pursuant to Section 1893(f)(2) for the overpayments. Note: Such interest may be payable for certain overpayments reversed at the Administrative Law Judge (ALJ) level or subsequent levels of appeal. Visit our website at www.Wpsmedicare.com for additional information and instructions for Immediate Recoupment. You may fax your request to the number mentioned at the end of this letter. Payment Withholding: If payment in full is not received by 02/19/2016, payments to you can be withheld (Recoupment) until payment in full is received or if you have not submitted an acceptable extended repayment request and/or a valid and timely appeal is received. Please complete an extended repayment schedule (ERS) package if you are unable to make full payment at this time, and would like to request an ERS. Details for completing the ERS package are included on our Website at www.Wpsmedicare.com. If you would like to receive an ERS package by mail, please call the telephone number listed at the end of this letter. Rebuttal Process: Under our existing regulations 42 CFR section 405.374, Providers and other Suppliers will have 15 days from the date of this demand letter to submit a statement of opportunity to rebuttal. The rebuttal process provides the debtor the opportunity to submit a statement and/or Page 3 Date : 01/21/2016 Letter Number : 19994075 s evidence stating why recoupment should not be initiated. The outcome of the rebuttal process ® could change how or if we recoup. If you have reason to believe the withhold should not occur on 03/01/2016, you must notify this office before 02/04/2016. We will review your documentation. Our office will advise you of our decision in 15 days from receipt of your request. However, this is not an appeal of the overpayment determination, and it will not delay recoupment before a rebuttal response has been rendered. The rebuttal statement does not cease recoupment activities consistent with section 935 of the MMA. How to Stop Recoupment: Even if the overpayment and any assessed interest has not been paid in full you can stop Medicare from recouping any payments. If you act quickly and decidedly, Medicare will permit providers to stop recoupment at two. points. The first occurs if we receive a valid and timely request for a redetermination within 30 days from the date of this letter. We will stop or delay recoupment pending the results of the appeal. We will again stop recoupment if, following an unfavorable or partially favorable redetermination decision if you decide to act quickly and file a valid request for reconsideration with the Qualified Independent Contractor (QIC). The address and details on how to file a request for reconsideration will be included in the redetermination decision letter. What are the timeframes to stop recoupment: First Opportunity: To assist us in expeditiously stopping the recoupment process, we request that you clearly indicate on your appeal request that this is a 935 overpayment appeal for a redetermination to: Wisconsin Physicians Service Ins. Corp. - 935 APPEALS REDETERMINATION P.O. Box 8833 Appeals Marion, IL 62959 Second Opportunity: If the redetermination decision is 1) unfavorable we can begin to recoup no earlier than the 60th day from the date of the Medicare redetermination notice (Medicare Appeal Decision Letter), or 2) if the decision is partially favorable we can begin to recoup no earlier than the 60th day from the date of the Medicare revised overpayment Notice/Revised Demand Letter. Therefore, it is important to act quickly and decidedly to limit recoupment by requesting a valid and timely reconsideration within 60 days of the appropriate notice/letter. The address and details on how to file a request for reconsideration will be included in the redetermination decision letter. What Happens following a reconsideration by a Qualified Independent Contractor (QIC): i Page 4 Date : 01/21/2016 Letter Number : 19994075 ' Following decision or dismissal by the QIC, if the debt has not been paid in full, we will begin a or resume recoupment whether or not you appeal to the next level of Administrative Law Judge (ALJ). NOTE: Even when recoupment is stopped, interest continues to accrue. Interest Assessment: If you do not refund in 30 days: In accordance with 42 CFR 405.378 simple interest at the rate of 9.75 percent will be charged on the unpaid balance of the overpayment beginning on the 31st day. Interest is calculated in 30-day periods and is assessed for each full 30-day period that payment is not made on time. Thus, if payment is received 31 days from the date of final determination, one 30-day period of interest will be charged. Each payment will be applied first to accrued interest and then to principal. After each payment interest will continue to accrue on the remaining principal balance, at the rate of 9.75 percent. In addition, please note that Medicare rules require that payment be either received in our office by 02/19/2016 or use the United States Postal Service Postmark by that date for the payment to be considered timely. A metered mail postmark received in our office after 02/19/2016 will cause an additional month's interest to be assessed on the debt. Medicaid Offset: If this matter is not resolved, CMS may instruct the Medicaid State Agency to withhold the Federal share of any Medicaid payments that may be due you or related facilities until the full amount owed Medicare is recouped, Title 42 CFR, Section 447.30(g). These recoveries will be in addition to any recoupments from other Medicare funds due you until the full amount owed to Medicare is recovered. If you wish to appeal this decision: If you disagree with this overpayment decision, you may file an appeal. An appeal is a review performed by people independent of those who have reviewed your claim so far. The first level of appeal is called a redetermination. You must file your request for a redetermination within 120 days from the date of this letter. However, if you wish to avoid recoupment from occurring, you need to file your request for redetermination within 30 days from the date of this letter as described above. Unless you show us otherwise, we assume you received this letter 5 days after the date of this letter. Please send your request for redetermination to: Wisconsin Physicians Service Ins. Corp. - 935 APPEALS REDETERMINATION P.O. Box 8833 Appeals Marion, IL 62959 I Invoice Number: 224816005700020 N Claim No. beneficiary ame HIC No. Service Date Service Date Amount Paid Date Provider No. From To Overpaid 221815124809900 FRANCES J OLAND 315282246A 44/29/2015 04/29/2015 $326.11 05/18/2015 1154325579 Reason for Overpayment: Based on Medicare Policy, services within a Skilled Nursing Facility period are subject to consolidated billing and should not be paid separately. Our records indicate that this claim is subject to Skilled Nursing Facility consolidated billing. Therefore, payment was made to you in error. Page 5 Date : 01/21/2016 Letter Number : 19994075 If you have filed a bankruptcy petition: If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding, Medicare financial obligations will be resolved in accordance with the applicable bankruptcy process. Accordingly, we request that you immediaft:fly notify us about this bankruptcy so that we may coordinate with both the Centers for Medicare & Medicaid Services and the Department of Justice so as to assure that we handle Your situation properly. If possible, when notifying us about the bankruptcy please include the name the bankruptcy is filed under and the district where the bankruptcy is filed. Should you have any questions, please contact your overpayment consultant at the following: Provider- Part B: 866-234-7331 Part B Extended Repayment Request: 866-234-7331 Part B immediate Recoupment- Fax: 608-224-3515 We look forward to hearing from you shortly, Sincerely, Medicare Part B Recovery Unit Enclosure: How This Overpayment Was Determined