TN 3 (05-92)

A. Policy

You must always complete the Detailed Explanation of Your Overpayment page.

B. Description

1. Mandatory Captions

The Detailed Explanation of Your Overpayment page(s) must always have two separate sections headed by the captions “Overpayment Summary” and “Why You Were Overpaid”.

EXCEPTION: If an overpayment is discovered for a month during a title II windfall offset period, see SI 02006.010 and follow instructions in SI 02006.010 C.4 to issue a manual overpayment notice.

2. Title XIX Facility

When we send an SSA-L8171-U3 to an overpaid recipient in current pay who resides in a medical facility where Medicaid pays more than half the cost of care (title XIX facility), we also use the caption “We Will Not Reduce Your SSI Check”. This caption should precede the mandatory captions, if possible.

C. Procedure

1. Recipient In Title XIX Facility

If the recipient resides in a title XIX facility per B.2 above, use the caption “We Will Not Reduce Your SSI Check” along with paragraph 2908 (NL 00804.260).

2. Overpayment Summary - General

1. Use paragraph 2923 (NL 00804.260) under the caption “Overpayment Summary” except when the amount of SSI due changed at least one time prior to detection of the current overpayment.

   NOTE: Paragraph 2923 has appropriate fill-in language for situations involving a federally administered State supplement.

2. Under the chart headings in paragraph 2923 list:

   • Each month in the period of incorrect payment;

   • The amount actually paid each month; and

   • The amount that should have been paid.

3. Amount Due Changed

1. Use paragraph 2924 (NL 00804.260) under the caption “Overpayment Summary,” instead of paragraph 2923, when:

   • There was a prior overpayment in a month in the new overpayment period;

   • We notified the individual about the old overpayment; and

   • The amount that should have been paid is now different from what we told the individual in the prior overpayment notice.

2. Paragraph 2924 also includes chart headings. Under the heading:

   • “Month” - List each month in the period of incorrect payment.

   • “Incorrect Amount for Each Month” - For any month we previously revised the due amount, show this revised due amount (amount due from prior overpayment notice) rather than what was actually paid.

   • “Correct Amount for Each Month” - List the amount that we should have paid based on current information.

4. Reason for Overpayment

Begin the last section of the explanation with the caption “Why You Were Overpaid.” When possible use the paragraphs listed below to explain the overpayment. (Unless otherwise indicated, these paragraphs are AONS paragraphs located in NL 00804.260. When standard paragraphs do not exist, the explanation must contain sufficient information for the recipient to determine if the facts on which we based the overpayment determination are correct.)