Medicare Summary Notices - English Exhibits - 1.2_BofA_120907.pdf

Page 1 of 6 Medicare Summary Notice for Part B (Medical Insurance) The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid Services THIS IS NOT A BILL JENNIFER WASHINGTON TEMPORARY ADDRESS NAME STREET ADDRESS CITY, ST 12345-6789 Your Deductible Status Your deductible is what you must pay for most health services before Medicare begins to pay. Part B Deductible: You have now met $85.00 of your $162.00 deductible for 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. Notice for Jennifer Washington Medicare Number XXX-XX-1234A Date of This Notice September 16, 2011 Claims Processed Between June 15 – September 15, 2011 Your Claims & Costs This Period Did Medicare Approve All Services? YES See page 2 for how to double-check this notice. Total You May Be Billed $0.00 Facilities with Claims This Period July 19 – August 22, 2011 The New York and Presbyterian Hospital ¿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) Exhibit 1.2 – ‘B of A’ THIS IS NOT A BILL | Page 2 of 6 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 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 1.2 – ‘B of A’ Service Provided & Billing Code Service Approved? Amount Facility Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Liver function blood test panel (80076) Yes $69.46 $69.46 $69.46 $0.00 A Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 A Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 A Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 A Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 A Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 A Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 A Claim #21035000422104NYA (continued) Jennifer Washington THIS IS NOT A BILL | Page 3 of 6 Part B Medical Insurance helps pay for outpatient care provided by certified medical facilities, such as hospital outpatient departments, renal dialysis facilities, and community health centers. Definitions of Columns Service Approved?: This column tells you if Medicare covered the outpatient service. Amount Facility Charged: This is your facility’s fee for this service. Medicare-Approved Amount: This is the amount a facility can be paid for a Medicare service. It may be less than the actual amount the facility charged. The facility has agreed to accept this amount as full payment for covered services. Medicare usually pays 80% of the Medicare-approved amount. Amount Medicare Paid: This is the amount Medicare paid the facility. This is usually 80% of the Medicare-approved amount. Maximum You May Be Billed: This is the total amount the facility is allowed to bill you, and can include a deductible, coinsurance, and other charges not covered. If you have Medicare Supplement Insurance (Medigap policy) or other insurance, it may pay all or part of this amount. Your Outpatient Claims for Part B (Medical Insurance) July 19 – August 22, 2011 The New York and Presbyterian Hospital, (555) 555-1234 525 East 68th Street, New York NY 10065-4870 Referred by Selim M. Arcasoy Continued Notes for Claims Above A This service is paid at 100% of the Medicare-approved amount. Exhibit 1.2 – ‘B of A’ Service Provided & Billing Code Service Approved? Amount Facility Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 B Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 B Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 B Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 B Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 B Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 B Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 B Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 B Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 B Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 B Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 B Drug screen (80101) Yes 81.68 81.68 81.68 0.00 B,C Vancomycin (antibiotic) level (80202) Yes 134.51 134.51 134.51 0.00 B Vancomycin (antibiotic) level (80202) Yes 134.51 134.51 134.51 0.00 B Vancomycin (antibiotic) level (80202) Yes 134.51 134.51 134.51 0.00 B Manual urinalysis test with examination using microscope (81001) Yes 47.41 47.41 47.41 0.00 B Claim #21035000422104NYA (continued) Jennifer Washington THIS IS NOT A BILL | Page 4 of 5 July 19 – August 22, 2011/The New York and Presbyterian Hospital continued... Notes for Claims Above B This service is paid at 100% of the Medicare-approved amount. C Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of LCD #L27375. Continued Exhibit 1.2 – ‘B of A’ Service Provided & Billing Code Service Approved? Amount Facility Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Manual urinalysis test with examination using microscope (81001) Yes 47.41 47.41 47.41 0.00 D Manual urinalysis test with examination using microscope (81001) Yes 47.41 47.41 47.41 0.00 D Manual urinalysis test with examination using microscope (81001) Yes 94.82 94.82 94.82 0.00 D Automated urinalysis test (81003) Yes 36.38 36.38 36.38 0.00 D Urine chloride level (82436) Yes 44.10 44.10 44.10 0.00 D Urine chloride level (82436) Yes 44.10 44.10 44.10 0.00 D Blood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 D Blood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 D Blood gases measurement (82805) Yes 485.12 485.12 485.12 0.00 D Blood gases measurement (82805) Yes 606.40 606.40 606.40 0.00 D Blood gases measurement (82805) Yes 606.40 606.40 606.40 0.00 D Blood gases measurement (82805) Yes 485.12 485.12 485.12 0.00 D Blood gases measurement (82805) Yes 485.12 485.12 485.12 0.00 D Blood gases measurement (82805) Yes 363.84 363.84 363.84 0.00 D Blood gases measurement (82805) Yes 363.84 363.84 363.84 0.00 D Blood gases measurement (82805) Yes 242.84 242.84 242.84 0.00 D Blood gases measurement (82805) Yes 242.56 242.56 242.56 0.00 D Blood gases measurement (82805) Yes 363.84 363.84 363.84 0.00 D Blood gases measurement (82805) Yes 242.56 242.56 242.56 0.00 D Chemical analysis using spectrophotometry (light) (84311) Yes 347.29 347.29 347.29 0.00 D Chemical analysis using spectrophotometry (light) (84311) Yes 347.29 347.29 347.29 0.00 D Thyroxine (thyroid chemical) measurement (84439) Yes 151.04 151.04 151.04 0.00 D Total for Claim #21035000422104NYA $7,672.94 $7,672.94 $7,915.50 $0.00 Jennifer Washington THIS IS NOT A BILL | Page 5 of 6 July 19 – August 22, 2011/The New York and Presbyterian Hospital continued... Notes for Claims Above D This service is paid at 100% of the Medicare-approved amount. Exhibit 1.2 – ‘B of A’ Jennifer Washington THIS IS NOT A BILL | Page 6 of 6 How to Handle Denied Claims or File an Appeal 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 Exhibit 1.2 – ‘B of A’