When a medicaid managed care organization seeks to recoup an overpayment made to a provider, it shall provide the provider all of the details of the recoupment, including all of the following information:

1. (A) The name, address, and medicaid identification number of the enrollee to whom the services were provided;
2. (B) The date or dates that the services were provided;
3. (C) The reason for the recoupment;
4. (D) The method by which the provider may contest the proposed recoupment.