Medicare Summary Notices - English Exhibits - 1.1_PartA_Inpatient_120907.pdf

Medicare Summary Notice for Part A (Hospital Insurance) The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid Services Your Deductible Status Your deductible is what you must pay each benefit period for most health services before Medicare begins to pay. Part A Deductible: You have now met your $1,068.00 deductible for inpatient hospital services for the benefit period that began May 27, 2011. Be Informed! Register at www.MyMedicare.gov for direct access to your Original Medicare claims, track your preventive services and print an “On the Go” report to share with your provider. Visit the Web site to sign up and access your personal Medicare information. THIS IS NOT A BILL JENNIFER WASHINGTON TEMPORARY ADDRESS NAME STREET ADDRESS CITY, ST 12345-6789 Notice for Jennifer Washington Medicare Number XXX-XX-1234A Date of This Notice September 16, 2011 Claims Processed Between June 15 – September 15, 2011 ¿Sabía que puede recibir este aviso y otro tipo de ayuda de Medicare en español? Llame y hable con un agente en español. 如果需要国语帮助，请致电联邦医疗保险，请先说“agent”, 然后说”Mandarin”. 1-800-MEDICARE (1-800-633-4227) Your Claims & Costs This Period Did Medicare Approve All Claims? YES See page 2 for how to double-check this notice. Total You May Be Billed $2,062.50 Facilities with Claims This Period June 18 – June 29, 2011 Otero Hospital July 1 – July 18, 2011 Lexington Health Center Page 1 of 5 Exhibit 1.1 – Part A, Inpatient THIS IS NOT A BILL | Page 2 of 5 Jennifer Washington Making the Most of Your Medicare How to Check This Notice Do you recognize the name of each facility? Check the dates. Did you get the claims listed? Do they match those listed on your receipts and bills? If you already paid the bill, did you pay the right amount? Check the maximum you may be billed. See if the claim was sent to your Medicare supplement insurance (Medigap) plan or other insurer. That plan may pay your share. How to Report Fraud If you think a facility or business is involved in fraud, call us at 1-800-MEDICARE (1-800-633-4227). Some examples of fraud include offers for free medical services, or billing you for Medicare services you didn’t get. If we determine that your tip led to uncovering fraud, you may qualify for a reward. You can make a difference! Last year, Medicare saved tax-payers $4 billion—the largest sum ever recovered in a single year—thanks to people who reported suspicious activity to Medicare. How to Get Help with Your Questions 1-800-MEDICARE (1-800-633-4227) Ask for “hospital services.” Your customer-service code is 05535. TTY 1-877-486-2048 (for hearing impaired) Contact your State Health Insurance Program (SHIP) for free, local health insurance counseling. Call 1-555-555-5555. Your Benefit Periods Your hospital and skilled nursing facility (SNF) stays are measured in benefit days and benefit periods. Every day that you spend in a hospital or SNF counts toward the benefit days in that benefit period. A benefit period begins the day you first receive inpatient hospital services or, in certain circumstances, SNF services, and ends when you haven’t received any inpatient care in a hospital or inpatient skilled care in a SNF for 60 days in a row. Inpatient Hospital: You have 56 out of 90 covered benefit days remaining for the benefit period that began May 27, 2011. Skilled Nursing Facility: You have 63 out of 100 covered benefit days remaining for the benefit period that began May 27, 2011. See your “Medicare & You” handbook for more information on benefit periods. Your Messages from Medicare Get a pneumococcal shot. You may only need it once in a lifetime. Contact your health care provider about getting this shot. You pay nothing if your health care provider accepts Medicare assignment. To report a change of address, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. Early detection is your best protection. Schedule your mammogram today, and remember that Medicare helps pay for screening mammograms. Do you use therapy services? Watch the limit! In 2011, Medicare’s annual coverage limit for most outpatient physical therapy and speech language pathology is $1,860 combined. Exhibit 1.1 – Part A, Inpatient Jennifer Washington THIS IS NOT A BILL | Page 3 of 5 Benefit Days Used Claim Approved? Non- Covered Charges Amount Medicare Paid Maximum You May Be Billed See Notes Below Benefit Period starting May 27, 2011 1 day Yes $0.00 $6,583.00 $0.00 Total for Claim #20906900033902 $0.00 $6,583.00 $0.00 A Part A Inpatient Hospital Insurance helps pay for inpatient hospital care, inpatient care in a skilled nursing facility following a hospital stay, home health care, and hospice care. Definitions of Columns Benefit Days Used: The number of covered benefit days you used during each hospital and/or skilled nursing facility stay. (See page 2 for more information and a summary of your benefit periods.) Claim Approved?: This column tells you if Medicare covered the inpatient stay. Non-Covered Charges: This is the amount Medicare didn’t pay. Amount Medicare Paid: This is the amount Medicare paid your inpatient facility. Maximum You May Be Billed: The amount you may be billed for Part A services can include a deductible, coinsurance based on your benefit days used, and other charges. For more information about Medicare Part A coverage, see your “Medicare & You” handbook. Your Inpatient Claims for Part A (Hospital Insurance) June 18 – June 21, 2011 Otero Hospital, (555) 555-1234 PO Box 1142, Manati, PR 00674 Referred by Jesus Sarmiento Forasti June 29, 2011 Otero Hospital, (555) 555-1234 PO Box 1142, Manati, PR 00674 Referred by Carlos Santiago Diaz Benefit Days Used Claim Approved? Non- Covered Charges Amount Medicare Paid Maximum You May Be Billed See Notes Below Benefit Period starting May 27, 2011 4 days Yes $0.00 $4,886.98 $0.00 Total for Claim #20905400034102 $0.00 $4,886.98 $0.00 A Continued Notes for Claims Above A Days are being subtracted from your total inpatient hospital benefits for this benefit period. The “Your Benefit Periods” section on page 2 has more details. Exhibit 1.1 – Part A, Inpatient Jennifer Washington THIS IS NOT A BILL | Page 4 of 5 Benefit Days Used Claim Approved? Non- Covered Charges Amount Medicare Paid Maximum You May Be Billed See Notes Below Benefit Period starting May 27, 2011 17 days Yes $0.00 $7,012.27 $2,062.50 Total for Claim #21034400232702ILA $0.00 $7,012.27 $2,062.50 B,C July 1 – July 18, 2011 Lexington Health Center, (555) 555-1234 815e Irving Park Rd, Streamwood, IL 60107-3073 Referred by Warren Pierce Notes for Claims Above B Days are being subtracted from your total skilled nursing facility benefits for this benefit period. The “Your Benefit Periods” section on page 2 has more details. C $2,062.50 was applied to your skilled nursing facility coinsurance. Exhibit 1.1 – Part A, Inpatient File an Appeal in Writing Follow these steps: 1 Circle the service(s) or claim(s) you disagree with on this notice. 2 Explain in writing why you disagree with the decision. Include your explanation on this notice or, if you need more space, attach a separate page to this notice. 3 Fill in all of the following: Your or your representative’s full name (print) Your or your representative’s signature Your telephone number Your complete Medicare number 4 Include any other information you have about your appeal. You can ask your facility for any information that will help you. 5 Write your Medicare number on all documents that you send. 6 Make copies of this notice and all supporting documents for your records. 7 Mail this notice and all supporting documents to the following address: Medicare Claims Office c/o Contractor Name Street Address City, ST 12345-6789 Get More Details If a claim was denied, call or write the hospital or facility and ask for an itemized statement for any claim. Make sure they sent in the right information. If they didn’t, ask the facility to contact our claims office to correct the error. You can ask the facility for an itemized statement for any service or claim. Call 1-800-MEDICARE (1-800-633-4227) for more information about a coverage or payment decision on this notice, including laws or policies used to make the decision. If You Need Help Filing Your Appeal Contact us: Call 1-800-MEDICARE or your State Health Insurance Program (see page 2) for help before you file your written appeal, including help appointing a representative. Call your facility: Ask your facility for any information that may help you. Ask a friend to help: You can appoint someone, such as a family member or friend, to be your representative in the appeals process. Find Out More About Appeals For more information about appeals, read your “Medicare & You” handbook or visit us online at www.medicare.gov/appeals. If You Disagree with a Coverage Decision, Payment Decision, or Payment Amount on this Notice, You Can Appeal Appeals must be filed in writing. Use the form to the right. Our claims office must receive your appeal within 120 days from the date you get this notice. We must receive your appeal by: January 14, 2011 Jennifer Washington THIS IS NOT A BILL | Page 5 of 5 How to Handle Denied Claims or File an Appeal Exhibit 1.1 – Part A, Inpatient Page 1 of 5 Medicare Summary Notice for Part A (Hospital Insurance) The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid Services Your Deductible Status Your deductible is what you must pay each benefit period for most health services before Medicare begins to pay. Part A Deductible: You have now met your $1,068.00 deductible for inpatient hospital services for the benefit period that began May 27, 2011. Be Informed! Register at www.MyMedicare.gov for direct access to your Original Medicare claims, track your preventive services and print an “On the Go” report to share with your provider. Visit the Web site to sign up and access your personal Medicare information. THIS IS NOT A BILL JENNIFER WASHINGTON TEMPORARY ADDRESS NAME STREET ADDRESS CITY, ST 12345-6789 ¿Sabía que puede recibir este aviso y otro tipo de ayuda de Medicare en español? Llame y hable con un agente en español. 如果需要国语帮助，请致电联邦医疗保险，请先说“agent”, 然后说”Mandarin”. 1-800-MEDICARE (1-800-633-4227) Your Claims & Costs This Period Did Medicare Approve All Claims? NO Number of Services Medicare Denied 2 See claims starting on page 3. Look for NO in the “Claim Approved?” column. See the last page for how to handle a denied claim. Total You May Be Billed $2,062.50 Facilities with Claims This Period June 18 – June 29, 2011 Otero Hospital July 1 – July 18, 2011 Lexington Health Center Notice for Jennifer Washington Medicare Number XXX-XX-1234A Date of This Notice September 16, 2011 Claims Processed Between June 15 – September 15, 2011 Exhibit 1.1 – Part A, Inpatient page 1 with denied claims