toggle
Quick Links: Skip to main page content

Menu


Letters

General Information

Title Letter ID
Acknowledgement of Full Payment (AFP) - Attorney SGL905NGHP
Acknowledgement of Full Payment (AFP) – Insurer 1 SGL910NGHP
Acknowledgment of Full Payment (AFP) - Beneficiary SGL900NGHP
Attorney Tells Us He No Longer Represents the Bene ML002NGHP
Beneficiary Deceased Legal Rep Info Needed ML054NGHP
Beneficiary Liability Demand Letter SGLDBLNGHP
Beneficiary No-Fault Demand Letter SGLDBNNGHP
Beneficiary Tells Us He Discharged Attorney ML003NGHP
Beneficiary Workers’ Compensation Demand Letter SGLDBWNGHP
Cannot Identify Check ML056NGHP
Check Received -Request Policy Limit or Settlement Info ML011NGHP
Claim Number for Insurer ML048NGHP
Compromise Referral to Regional Office ML044NGHP
Demand Letter ML041NGHP
DOJ OGC Letter ML061NGHP
DPP Referral to Other Medicare Contractor ML012NGHP
Exhaust Letter Benefits Exhausted - Beneficiary SGLB42NGHP
Exhaust Letter Benefits Exhausted - Insurer SGLI42NGHP
Exhaust Letter, Case Closed, Liability Pending ML043NGHP
Insufficient Refund – Balance is Due (IRB) - Attorney SGL945NGHP
Insufficient Refund – Balance is Due (IRB) - Beneficiary SGL940NGHP
Insufficient Refund – Balance is Due (IRB) – Insurer 1 SGL950NGHP
Insurer Liability Demand Letter SGLDILNGHP
Insurer No-Fault Demand Letter SGLDINNGHP
Insurer Payment Log Request - Insurer SGLI05NGHP
Insurer Payment Log Request- Insurer 1 SGL802NGHP
Insurer Workers’ Compensation Demand Letter SGLDIWNGHP
Intent to Refer, Principal & Interest, Beneficiary SGL200NGHP
Intent to Refer, Principal & Interest, Insurer 1 SGL400NGHP
Medicare Case is Closed – Zero Interest - Attorney SGLA34NGHP
Medicare Case is Closed – Zero Interest - Beneficiary SGLB34NGHP
Medicare Case is Closed – Zero Interest - Insurer SGLI34NGHP
No Claims Paid by Medicare - Insurer SGLI08NGHP
No Claims Paid by Medicare – Attorney SGLA08NGHP
No Claims Paid by Medicare – Beneficiary SGLB08NGHP
No-Fault Pre-Demand Letter SGLNPDNGHP
Procurement Exceeds Settlement ML049NGHP
Redetermination Acknowledgment Letter ML057NGHP
Redetermination Letter ML058NGHP
Redetermination Request to Vacate Letter ML059NGHP
Redetermination Withdrawal Letter ML060NGHP
Request Documentation Procurement Exceeds Settlement ML050NGHP
Request Settlement Info from Attorney SGLA09NGHP
Revised Demand ML013NGHP
SKL Status Letter - Insurer SGLI10NGHP
SKL Status Letter – Attorney SGLA10NGHP
SKL Status Letter – Beneficiary SGLB10NGHP
WCSA Arrangement to COBC ML055NGHP

Release Agreement Form

Title Letter ID
Cannot Identify the Beneficiary ML004NGHP
Need more Information about Incident ML007NGHP

Conditional Payment

Title Letter ID
Conditional Payment Letter ML040NGHP
Disputed Claims on Conditional Payment ML035NGHP
Enclosure - Summary of Claims in Question ML035NGHP_encl.
Liability Conditional Payment Letter SGLLCPNGHP
Workers’ Compensation Conditional Payment Letter SGLWCPNGHP

Repayment

Title Letter ID
Denied Installment Letter ML052NGHP
Extended Repayment Plan Beneficiary ML051NGHP
Extended Repayment Plan Beneficiary Fails to Remit Payment ML053NGHP
Referral to HIGLAS Contractor ML015NGHP
Request for Petition for Bankruptcy/Liquidation, Beneficiary/Attorney ML016NGHP

Waiver

Title Letter ID
Acknowledgement Waiver from Attorney ML017NGHP
Acknowledgement Waiver from Beneficiary ML018NGHP
Cannot Do Waiver, No Settlement ML036NGHP
Deny Waiver No Refund Received Balance Due ML019NGHP
Deny Waiver Paid In Full No Refund Due ML020NGHP
Full Waiver No Refund Received ML022NGHP
Partial Waiver No Refund Received Balance Due to Medicare ML024NGHP
Partial Waiver Paid In Full Medicare Owes Refund ML025NGHP
Partial Waiver Partial Payment Balance Due ML027NGHP