The purpose of this letter is to advise your office of suspected
Medicare fraud and abuse.
This complaint involves
ADDR7
BFREE6
, I wrote a letter to
ADDR7
A copy of my letter is attached for your reference.
I spoke with
and was advised to
BFREE6
If you have any questions or need additional information, please
contact me at the address given above.
I can also be contacted by phone at
extension
extension
A fax can be sent to
Thank you for your assistance in this matter.
UNBILL02
UNBILL02
UNBILL02
UNBILL02
UNBILL02
UNBILL02
UNBILL02
UNBILL02
UNBILL01 OpeningUNBILL02 Purpose
This required section statesthe names and addresses of theperson making the complaintand the person or office towhom this letter is beingsent. Press [Ctrl+F1] formore information.This required section statesthe name of the party who issuspected of Medicare fraudand abuse, and the nature ofthe fraud and abuse.Press [Ctrl+F1] for moreinformation.
REQUIRED TRANSFER SECTIONCount Field 1 1 Marked if "second letter" radio button on screen 1 is selected. TO DATE
REQUIRED OPENING SECTION (SECTION 1 OF 2) [Optional - From Address] F R O M [First letter about this particular complaint (to be sent to the Medicare carrier) Second letter about this particular complaint (to be sent to the Medicare carrier or the Inspector General Hotline)] T O Re: Medicare No.
* f
This required section includes the names and addresses of the personmaking the complaint and the person or office to whom the complaintis being sent. It also specifies whether this is the first orsecond letter dealing with this matter. Access the Expert Guide formore information.Enter an X to include the name and address of the person writingthe complaint.Enter the name of the person who is writing the complaint regardingunnecessary or inappropriate services or billing. Press [F2] toselect and paste a record from the Address Manager. Access theExpert Guide for more information.Enter the person's street address or edit the information asdesired.Enter the person's extended street address or edit the informationas desired.Enter the person's city or edit the information as desired.Enter the person's state or edit the information as desired. Press[F8] to select a state from the selection box.Enter the person's zip/postal code or edit the information asdesired.Enter an X to include the person's country.Enter the country or edit the information as desired.Enter an X if you have NOT previously written to the Medicarecarrier about this particular complaint.Enter an X if you have not received a satisfactory response from theMedicare carrier about this particular complaint. Access the ExpertGuide for information regarding the Medicaid Fraud and AbuseHotline.Enter the name of the contact person, if known. Press [F2] toselect and paste a record from the Address Manager. Access theExpert Guide for address information if the beneficiary lives inCALIFORNIA, KANSAS, MARYLAND, MINNESOTA, MISSOURI, NEW YORK, orVIRGINIA.Enter the title of the contact person, if known. Access the ExpertGuide for address information if the beneficiary lives inCALIFORNIA, KANSAS, MARYLAND, MINNESOTA, MISSOURI, NEW YORK, orVIRGINIA.Enter the name of the Medicare carrier that handles your claims oredit the information as desired. Access the Expert Guide foraddress information if the beneficiary lives in CALIFORNIA, KANSAS,MARYLAND, MINNESOTA, MISSOURI, NEW YORK, or VIRGINIA.Enter the carrier's street address or edit the information asdesired.Enter the carrier's extended street address or edit the informationas desired.Enter the carrier's city or edit the information as desired.Enter the carrier's state or edit the information as desired. Press[F8] to select a state from the selection box.Enter the carrier's zip code or edit the information as desired.Enter an X to include the carrier's country, if outside the UnitedStates.Using the format MM/DD/YYYY, enter the date of the letter or editthe date as desired.Enter an X to include a subject for this letter.Enter your Medicare number as listed on your Medicare card. Thisnumber has nine digits and a letter. There may also be anothernumber after the letter.
REQUIRED PURPOSE SECTION (SECTION 2 OF 2) : The purpose of this letter is to advise your office of suspected Medicare fraud and abuse. This complaint involves , of , . On , [Previous contact information] On , I wrote a letter to , of , . A copy of my letter is attached for your reference. I spoke with on , and was advised to If you have questions or need additional information, please contact me at the address given above. I can also be contacted by phone at extension or extension . A fax can be sent to . Thank you for your assistance in this matter. [Optional enclosure and carbon copy lines]
This required section states the name of the party who is suspectedof Medicare fraud and abuse, and the nature of the fraud and abuse.Access the Expert Guide for more information.Enter a salutation or edit the information as desired. Press [F8]to select a salutation from the selection box. If this field or thefollowing name field is left blank, it will not be printed.If previously entered, a contact person's name will be transferredto this field. If desired, you may modify the information withoutaffecting earlier data.Enter the name of the party who is suspected of Medicare fraud andabuse.Enter the party's street address.Enter the party's extended street address.Enter the party's city.Enter the party's state/province or press [F8] to select a statefrom the selection box.Enter the party's zip/postal code.Using the format MM/DD/YYYY, enter the date of the allegedwrongdoing.Describe the exact nature of the suspected Medicare abuse such asunnecessary or inappropriate services or an inappropriate billing.The program includes prior contact information if you indicatedthat this is not your first letter regarding this particularcomplaint.Using the format MM/DD/YYYY, enter the date you wrote the initialletter.Enter the name of the agency or person with whom you previouslycorresponded regarding the suspected abuse.Enter an X if a copy of the initial complaint is attached.Enter an X to include a sentence describing the advice received whenyou advised someone else of the suspected abuse.Enter the name of the person with whom you spoke, regarding thesuspected abuse.Using the format MM/DD/YYYY, enter the date you spoke with someoneregarding the suspected abuse.Describe the advice that was given to you subsequent to your initialcontact regarding the suspected abuse.Enter an X to include a sentence with telephone numbers at which youcan be reached. You may enter a daytime number, a number forevenings/weekends, or both.Enter an X to include phone numbers where you can be reached.Enter an X to include a phone number where you can be reached duringnon-business hours.Enter a non-business phone number or edit the information asdesired.Enter an X to include a phone extension number.Enter a phone extension number or edit the information as desired.Enter an X to include a phone number at which you can be reachedduring business hours.Enter a business phone or edit the information as desired.Enter a X to include a phone extension number.Enter a phone extension number or edit the information as desired.Enter an X to include a facsimile number.Enter a facsimile number or edit the information as desired.Enter a closing or edit the information as desired. Press [F8] toselect a closing from the selection box.The program completes the name by transferring the information froma previous section. If desired, you may change the name withoutaffecting earlier data.Enter an X to include a listing of attachments, enclosures, orpersons to whom copies of the letter are being sent.Use this space to enter information regarding enclosures or copies.Press [F8] to make a selection from the selection box. For example,"Enclosure" or "Copy To".Use this space to enter corresponding information. For example, adescription of the enclosure(s) or the name of a party receiving acopy.
(.txt)