March 21, 2017
Provider Name
Provider Address
Provider Number: XXXXXXX
SFY11 & SFY12 LTC Overpayment Reports
Dear Provider:
SFY11
The Bureau of Program Integrity has actively worked on your Overpayment Report, and at present your
potential overpayment amount for SFY11 is $X,XXX.xx.
If the amount of potential overpayment shown above is $0 (zero), no further action is required on your
part and we will close the SFY11 period for your facility in our system.
If the potential overpayment amount above is not $0 (zero), you may contact the assigned auditor listed
at the end of this letter. The auditor will provide a detailed report and review open items with you and
help you determine what type of documentation, if any, is needed to resolve any open items. The auditor
will work with you to establish deadlines and methods for submission of any required documentation.
If you agree with the SFY11 potential overpayment amount listed above and do not require a detailed
report at this time, you may simply inform the auditor assigned to your Overpayment Report. We will
then begin the final notification and collection process. The final packet will include a copy of the report.
SFY12
The Bureau of Program Integrity will be mailing the SFY12 Overpayment Report to you within the next
few weeks if any potential overpayment was identified. The auditor assigned to your SFY11 report will
also be working on any SFY12 report. Any questions as to either year should be sent to this auditor.
Included with the Overpayment Report will be a cover sheet instructing you on your rights and
responsibilities. Also included will be the form entitled Final Post-Payment Claims Overpayment Review
Response Form. This form will give you the opportunity to agree with the initial amount owed, participate
in the resolution process, or participate in the reconsideration process. This form must be returned to
ODM within 30 days of receiving the Overpayment Report. If it is not returned to ODM within 30 days,
the full initial amount owed will be considered final and will be offset against a future claim. You may
return this form to the address listed on it or to your assigned auditor’s e-mail address shown below.
Please also copy the general LTC Audit e-mail address listed below.
Note: Please be sure any e-mail sent to ODM that contains protected health information (PHI) or
personally identifiable information (PII) is secure and encrypted to meet Health Insurance Portability and
Accountability Act (HIPAA) and any other applicable requirements.
Please feel free to contact your assigned auditor anytime should you have questions or concerns.
We look forward to working with you to complete this work in an effective and efficient manner.
Assigned Auditor: Name of Assigned Auditor
Email Address:
Assigned Auditor’s Email Address
Direct Line:
Assigned Auditor’s Phone Number
General E-mail:
[email protected]
Respectfully,
John Maynard, CPA
Chief, Bureau of Program Integrity
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