NOTICE OF CHANGE IN OVERPAYMENT FOR MEDICAL ASSISTANCE
Date:
Name:
Address:
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.
We recently reviewed your Medicaid overpayment and determined your total overpayment has
for the reason listed below:
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.
As a reminder, 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
Prog
ram Code:
PDC ID:
PLC ID:
County Department of S
oc
ial S
ervices
c
c: fil
e c
opy
S
i nece
sita 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.
DHB-7059 Revised 1/2021
You provided additional documentation related to your overpayment. We carefully evaluated
the documentation and determined you were eligible for assistance during all or part of the
overpayment period. The new overpayment amount is _____________ for the period of
_____________ - _____________.
We determined there was an error in the original calculation of the overpayment amount and/or
period. The new overpayment amount is _____________ for the period of _____________ -
_____________.
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 due to providers having 365 days to file a claim. The new overpayment amount is
_____________ for the period of _____________ - _____________.
Other:______________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
