From: CMS RDS Payment [mailto:RDSpayment@cms.hhs.gov]
Sent: Monday, June 30, 2008 2:56 PM
To: Sample Plan Sponsor
Cc: Account Manager
Subject: RDS Overpayment Notification for App 1XXX0

Dear Sample Plan Sponsor:

This notice is to inform Sample Plan Sponsor that the Centers for Medicare & Medicaid Services (CMS) Retiree Drug Subsidy (RDS) Center has determined that there has been an overpayment in an amount of $XX.36 with regard to the following RDS application:

Application Number:1XXX0

Plan Sponsor ID: XXXX

Plan Year Start Date:7/1/2005

Plan Year End Date:6/30/2006

Reconciliation Deadline:6/30/2008

Reason for Initial Determination of Overpayment:

The sum of actual allowable retiree costs (ARC) attributable to gross costs between the cost threshold and cost limit, submitted with the reconciliation payment request, was less than the sum of ARC attributable to such costs, submitted with the interim payment request(s); therefore, the amount of retiree drug subsidies received from interim payments was greater than what should have been received.

Please remit payment in full by sending a check or money order, made out to the Centers for Medicare & Medicaid Services, to the following address.

Retiree Drug Subsidy Center

Attn: Payments

P.O. Box 6865

Towson, MD 21204

Please include the Plan Sponsor ID on the check or money order.

Plan Sponsors will receive e-mail confirmation of receipt of any such check or money order.

Please note that CMS reserves the right to assess interest and refer any outstanding amount to the U.S. Department of Treasury for collection.

If you do not agree with this determination, you may submit a written request for an informal written reconsideration of this determination, as specified in Federal regulations at 42 CFR §423.890(a).

The reconsideration request must be made through the RDS Secure Web Site no later than 15 calendar days from the date of this notice in order to be considered. For instructions on how to submit an informal written reconsideration request, go to “How To Request an Informal Written Reconsideration” located on the RDS Program Web Site at  http://rds.cms.hhs.gov/how_to/appeals.htm

If you have further questions, please call CMS' RDS Help Line at (877) RDS-HELP, or (877) 737-4357. TTY for the hearing impaired: (877) RDS-TTY0, or (877) 737-8890.

Sincerely,

CMS’ RDS Center

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