Medicare Summary Notices - English Exhibits - 2.10_Breaking_LongNotes_120409.pdf

Service Provided & Billing Code Service Approved? Amount Provider Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Xray of thigh, 2 views professional charge (73550-26LT) Yes $38.00 $8.83 $7.06 $1.77 CT scan head or brain professional charge (70450-62GZ) Yes 179.00 0.00 0.00 0.00 A,B Total for Claim #11-10336-697-750 $217.00 $8.83 $7.06 $1.77 C Jennifer Washington THIS IS NOT A BILL | Page 3 of 7 Part B Medical Insurance helps pay for doctors’ services, diagnostic tests, ambulance services, and other health care services. Definitions of Columns Service Approved?: This column tells you if Medicare covered this service. Amount Provider Charged: This is your provider’s fee for this service. Medicare-Approved Amount: This is the amount a provider can be paid for a Medicare service. It may be less than the actual amount the provider charged. Your provider 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 your provider. This is usually 80% of the Medicare-approved amount. Maximum You May Be Billed: This is the total amount the provider 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) November 15, 2010 Dr. Martin Simmerman, P.M. M.D., (555) 555-1234 Arnette Clinic, LLC, 8016 Reliable Pkwy, Chicago, IL 60686-0001 Referredy by Alaimo, Andrew A Continued Notes for Claims Above A 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 #L28516. B It appears that you did not know that we would not pay for this service, so you are not liable. Do not pay your provider for this service. If you have paid your provider for this service, you should submit to this office three things: 1) a copy of this notice, 2) your provider’s bill, and 3) a receipt or proof that you have paid the bill. You must file your written request for payment within 6 months of the date of this notice. Future services of this type provided to you will be your responsibility. C 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 2.10 – Breaking Claims with Long Notes Service Provided & Billing Code Service Approved? Amount Provider Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function professional charge (93306-26) Yes $211.00 $69.84 $55.87 $13.97 Total for Claim #11-10340-695-690 $211.00 $69.84 $55.87 $13.97 D Service Provided & Billing Code Service Approved? Amount Provider Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Xray of knee, 3 views professional charge (73562-26LT) Yes $40.00 $9.56 $7.65 $1.91 CT scan abdomen professional charge (74150-26) Yes 238.00 60.20 48.16 12.04 CT scan pelvis professional charge (72192-26) Yes 211.00 55.23 44.18 11.05 Xray of shoulder, minimum of 2 views professional charge (73030-26LT) Yes 42.00 9.56 7.65 1.91 Total for Claim #11-10217-667-100 $531.00 $134.55 $107.64 $26.91 D Jennifer Washington THIS IS NOT A BILL | Page 4 of 7 November 17, 2011 Dr. Priit Jaagosild, M.D., (555) 555-1234 Arnette Clinic, LLC, 8016 Reliable Pkwy, Chicago, IL 60686-0001 Referredy by Dupre, Gary W November 17, 2011 Dr. Martin Simmerman, P.M. M.D., (555) 555-1234 Arnette Clinic, LLC, 8016 Reliable Pkwy, Chicago, IL 60686-0001 Referredy by Alaimo, Andrew A Continued Notes for Claims Above 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 2.10 – Breaking Claims with Long Notes Service Provided & Billing Code Service Approved? Amount Provider Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below November 18, 2011 Physical therapy evaluation (97001-GP) Yes $100.00 $78.83 $15.00 $0.00 E Application of hot or cold packs to 1 or more areas (97010-GP) Yes 10.00 0.00 0.00 0.00 F,G,H Therapeutic procedure to re- educate brain-to-nerve-to-muscle function, each 15 minutes (97112-GP) Yes 60.00 33.31 0.00 0.00 I Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes (97110-GP) Yes 50.00 32.00 0.00 0.00 J November 20, 2011 Therapeutic procedure to re- educate brain-to-nerve-to-muscle function, each 15 minutes (97112-GP) Yes 60.00 33.31 0.00 0.00 Claim #83-11011-003-050 (continued) Jennifer Washington THIS IS NOT A BILL | Page 5 of 7 November 18 – November 20, 2011 Dr. Priit Jaagosild, M.D., (555) 555-1234 Arnette Clinic, LLC, 8016 Reliable Pkwy, Chicago, IL 60686-0001 Referredy by Dupre, Gary W Continued Notes for Claims Above E Your provider agreed to accept $68.00 as payment in full on this claim. Your primary insurer has already paid $53.00 so Medicare’s payment is the difference between the two amounts. F Payment is included in another service received on the same day. G You do not have to pay this amount. H If you have already paid it, you are entitled to a refund from this provider. I Your primary insurer approved and paid $60.00 on this claim. Therefore, no secondary payment will be made by Medicare. J Your primary insurer approved and paid $50.00 on this claim. Therefore, no secondary payment will be made by Medicare. Exhibit 2.10 – Breaking Claims with Long Notes Service Provided & Billing Code Item Approved? Amount Provider Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes (97110-GP) Yes 50.00 32.00 0.00 0.00 K,L,M Total for Claim #83-11011-003-050 $290.00 $177.45 $30.00 $0.00 N,O,P Jennifer Washington THIS IS NOT A BILL | Page 6 of 7 November 18 – November 20, 2011/Dr. Priit Jaagosild, M.D. continued... Notes for Claims Above K Payment is included in another service received on the same day. L You do not have to pay this amount. M If you have already paid it, you are entitled to a refund from this provider. N 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. O Of the $30.00 paid on this claim, we are paying you $15.00 because you paid your provider more than your 20 percent coinsurance on Medicare approved services. The remaining $15.00 was paid to the provider. P $1735.94 has been applied during this calendar year 2010 towards the $1,860.00 limit on outpatient physical therapy and speech-language pathology benefits. Exhibit 2.10 – Breaking Claims with Long Notes