Medicare Summary Notices - English Exhibits - 1.8_DME_Assigned_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. Your Claims & Costs This Period Did Medicare Approve All Items and Services? YES See page 2 for how to double-check your notice. Total You May Be Billed $61.31 Suppliers with Claims This Period May 9, 2011 Lincare Inc. June 12, 2011 Prof Healing Solutions July 6 – August 8, 2011 Walgreens Co ¿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) 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 1.8 – DME, Assigned 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 supplier? Check the dates. Did you make a purchase that day? Did you get the items/services 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 supplier 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 “medical supplies.” 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 1.8 – DME, Assigned Quantity, Item/Service Provided & Billing Code Item/ Service Approved? Amount Supplier Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below 1 oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concen (E1390-RR) Rental Yes $442.00 $173.17 $138.54 $34.63 A Total for Claim #10334829487000 $442.00 $173.17 $138.54 $34.63 B Jennifer Washington THIS IS NOT A BILL | Page 3 of 6 Part B Medical Insurance helps pay for durable medical equipment and other health care services. Definitions of Columns Item/Service Approved?: This column tells you if Medicare covered this item or service. Amount Supplier Charged: This is your supplier’s fee for this item or service. Medicare-Approved Amount: This is the amount a supplier can be paid for a Medicare item or service. It may be less than the actual amount the supplier charged. Your supplier has agreed to accept this amount as full payment for covered items or services. Medicare usually pays 80% of the Medicare-approved amount. Amount Medicare Paid: This is the amount Medicare paid the supplier. This is usually 80% of the Medicare-approved amount. Maximum You May Be Billed: This is the total amount the supplier 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 Claims for Part B (Medical Insurance) May 9, 2011 Lincare Inc., (555) 555-1234 PO BOX 996, Blue Springs, MO 64013-0996 Ordered by John K Whalen Continued Notes for Claims Above A Medicare will pay for you to rent this equipment for up to 36 months (or until you no longer need the equipment). After the 36 month rental period, Medicare will continue to pay for delivery of liquid and gaseous contents, as long as it is still medically necessary. B Your claim was sent to your Medicare Supplement Insurance (Medigap policy), Wellmark BlueCross BlueShield of N. Carolina. Send any questions regarding your benefits to them. Exhibit 1.8 – DME, Assigned Quantity, Item/Service Provided & Billing Code Item/ Service Approved? Amount Supplier Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below 1 portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifie (E0431-RR) Rental Yes $117.61 $28.77 $23.02 $5.75 C Total for Claim #10334829489000 $117.61 $28.77 $23.02 $5.75 D Quantity, Item/Service Provided & Billing Code Item/ Service Approved? Amount Supplier Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below 63 conforming bandage, non- elastic, knitted/woven, sterile, width greater than or equal to three inches (A6446-A1) Yes $31.00 $27.09 $21.67 $5.42 Total for Claim #10323807216000 $31.00 $27.09 $21.67 $5.42 D Jennifer Washington THIS IS NOT A BILL | Page 4 of 6 May 9, 2011 Lincare Inc., (555) 555-1234 PO BOX 996, Blue Springs, MO 64013-0996 Ordered by John K Whalen June 12, 2011 Prof Healing Solutions, (555) 555-1234 2497 S Roane St, Ste 220, Harriman, TN 37748-8689 Ordered by Barry Dick Notes for Claims Above C Medicare will pay for you to rent this equipment for up to 36 months (or until you no longer need the equipment). After the 36 month rental period, Medicare will continue to pay for delivery of liquid and gaseous contents, as long as it is still medically necessary. D Your claim was sent to your Medicare Supplement Insurance (Medigap policy), Wellmark BlueCross BlueShield of N. Carolina. Send any questions regarding your benefits to them. Exhibit 1.8 – DME, Assigned Quantity, Item/Service Provided & Billing Code Item/ Service Approved? Amount Supplier Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below 2 blood glucose test or reagent strips for home blood glucose monitor, per 50 strips (A4253- NUKX) Specific Required Documentation Yes $124.99 $77.56 $62.05 $15.51 Total for Claim #10320806344000 $124.99 $77.56 $62.05 $15.51 E Jennifer Washington THIS IS NOT A BILL | Page 5 of 6 July 6 – August 8, 2011 Walgreen Co, (555) 555-1234 PO BOX 90482, Chicago, IL 60696-0482 Ordered by Patrick T Burns Notes for Claims Above E Your claim was sent to your Medicare Supplement Insurance (Medigap policy), Wellmark BlueCross BlueShield of N. Carolina. Send any questions regarding your benefits to them. Exhibit 1.8 – DME, Assigned Jennifer Washington THIS IS NOT A BILL | Page 6 of 6 How to Handle Denied Claims or File an Appeal Get More Details If a claim was denied, call or write the supplier and ask for an itemized statement for any claim. Make sure they sent in the right information. If they didn’t, ask the supplier to contact our claims office to correct the error. You can ask the supplier for an itemized statement for any item 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 supplier: Ask your supplier 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, 2012 File an Appeal in Writing Follow these steps: 1 Circle the item(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 supplier 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 Exhibit 1.8 – DME, Assigned