Form Dma-7059 - Notice Of Change In Overpayment For Medical Assistance printable pdf download

Form Dma-7059 - Notice Of Change In Overpayment For Medical Assistance

NOTICE OF CHANGE IN OVERPAYMENT FOR MEDICAL ASSISTANCE

Date: _____________________

Name:

_____________________________

Program Code: _________________

Address: _____________________________

EIS Case ID:

_________________

_____________________________

SSN:

_________________

_____________________________

County Case ID: _________________

Dear _______________________:

You were notified on _____________________ that you are responsible for a medical

assistance overpayment because you and/or members of your household for whom you

are financially responsible received Medicaid or NC Health Choice benefits that you were

ineligible to receive. The original “Notice of Overpayment for Medical Assistance” informed

you that the amount of your overpayment would increase if additional medical expenses

were paid for the period of ineligibility.

We have reviewed the medical expenses paid during the period of ineligibility and your total

overpayment is $ _________________. The amount you currently owe on this debt will be

reduced by all payments that have been made. You can contact me at the number below

to verify the amount you currently owe on this debt.

You must make every effort to repay the full amount owed. If you have not previously

signed a voluntary repayment agreement, contact me at the number below to make

arrangements to establish a repayment schedule in order to prevent further collection

action. If you have questions about your current repayment agreement, contact me to

schedule an appointment to review your current repayment agreement.

Sincerely,

________________________________________

Program Integrity Investigator

______________ County Dept. of Social Services

(______)_________________________________

cc: file copy

Si necesita ayuda para entender esta carta de notificación de un pago excesivo por

asistencia médica, comuníquese con la unidad de integridad de este programa en el

departamento de servicios sociales del condado indicado arriba.

Issued 10/2011

DMA-7059

Form Dma-7059 - Notice Of Change In Overpayment For Medical Assistance