Medicare Summary Notices - English Exhibits - 2.11_Combined_A_121015.pdf

Medicare Summary Notice for Part A (Hospital Insurance) and Part B (Medical 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 June 18, 2010. Part B Deductible: You have met 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. 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) Facilities and Providers with Claims This Period July 29 – September 3, 2011 Otero Hospital September 20 – October 10, 2011 Heartland Home Health Care October 20 – November 23, 2011 The New York and Presbyterian Hospital Page 1 of 26 Notice for Jennifer Washington Medicare Number XXX-XX-1234A Date of This Notice December 16, 2011 Claims Processed Between October 15 – December 15, 2011 Your Claims & Costs This Period Did Medicare Approve All Claims and Services? YES See page 2 for how to double-check this notice. Total You May Be Billed $119,607.64 Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health THIS IS NOT A BILL | Page 2 of 26 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 used all of your 90 covered benefit days for the benefit period that began June 18, 2010. Inpatient Lifetime Reserve: You have used all of your 60 lifetime reserve days. 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 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington THIS IS NOT A BILL | Page 3 of 26 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) July 29 – September 3, 2011 The New York and Presbyterian Hospital, (555) 555-1234 525 East 68th Street, New York NY 10065-4870 Referred by Jesse Wilt Benefit Days Used Claim Approved? Non- Covered Charges Amount Medicare Paid Maximum You May Be Billed See Notes Below Benefit Period starting June 18, 2009 13 days Yes $112,431.00 $13,477.52 $119,373.00 A Total for Claim #20905400034102 $112,431.00 $13,477.52 $119,373.00 B,C Continued Notes for Claims Above A Services after 08/10/09 cannot be paid because your benefits were exhausted. B 13 of the Benefit Days were charged to your Lifetime Reserve Day benefit. C This service is paid at 100% of the Medicare approved amount. Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington THIS IS NOT A BILL | Page 4 of 26 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) October 20 – November 23, 2011 The New York and Presbyterian Hospital, (555) 555-1234 525 East 68th Street, New York NY 10065-4870 Referred by Selim M. Arcasoy 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 D Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 D Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 D Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 D Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 D Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 D Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 D Claim #21035000422104NYA (continued) Continued Notes for Claims Above D This service is paid at 100% of the Medicare approved amount. Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington THIS IS NOT A BILL | Page 5 of 26 Ocboter 20 – November 23, 2011/The New York and Presbyterian Hospital continued... 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 E Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 E Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 E Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 E Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 E Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 E Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 E Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 E Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 E Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 E Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 E Drug screen (80101) Yes 81.68 81.68 81.68 0.00 E,F Vancomycin (antibiotic) level (80202) Yes 134.51 134.51 134.51 0.00 E Vancomycin (antibiotic) level (80202) Yes 134.51 134.51 134.51 0.00 E Vancomycin (antibiotic) level (80202) Yes 134.51 134.51 134.51 0.00 E Manual urinalysis test with examination using microscope (81001) Yes 47.41 47.41 47.41 0.00 E Claim #21035000422104NYA (continued) Continued Notes for Claims Above E This service is paid at 100% of the Medicare approved amount. F 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. Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington THIS IS NOT A BILL | Page 6 of 26 Ocboter 20 – November 23, 2011/The New York and Presbyterian Hospital continued... 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 G Manual urinalysis test with examination using microscope (81001) Yes 47.41 47.41 47.41 0.00 G Manual urinalysis test with examination using microscope (81001) Yes 94.82 94.82 94.82 0.00 G Automated urinalysis test (81003) Yes 36.38 36.38 36.38 0.00 G Urine chloride level (82436) Yes 44.10 44.10 44.10 0.00 G Urine chloride level (82436) Yes 44.10 44.10 44.10 0.00 G Blood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 G Blood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 G Blood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 G Blood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 G Blood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 G Blood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 G Blood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 G Blood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 G Blood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 G Blood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 G Blood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 G Blood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 G Blood gases measurement (82805) Yes 363.84 363.84 363.84 0.00 G Blood gases measurement (82805) Yes 242.56 242.56 242.56 0.00 G Chemical analysis using spectrophotometry (light) (84311) Yes 347.29 347.29 347.29 0.00 G Chemical analysis using spectrophotometry (light) (84311) Yes 347.29 347.29 347.29 0.00 G Thyroxine (thyroid chemical) measurement (84439) Yes 151.04 151.04 151.04 0.00 G Thyroid hormone, T3 measurement (84481) Yes 256.88 256.88 256.88 0.00 G Claim #21035000422104NYA (continued) Continued Notes for Claims Above G This service is paid at 100% of the Medicare approved amount. Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington THIS IS NOT A BILL | Page 7 of 26 Ocboter 20 – November 23, 2011/The New York and Presbyterian Hospital continued... Continued Notes for Claims Above H This service is paid at 100% of the Medicare approved amount. Service Provided & Billing Code Service Approved? Amount Facility Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Red blood cell concentration measurement (85014) Yes 19.85 19.85 19.85 0.00 H Red blood cell concentration measurement (85014) Yes 59.55 59.55 59.55 0.00 H Red blood cell concentration measurement (85014) Yes 39.70 39.70 39.70 0.00 H Red blood cell concentration measurement (85014) Yes 39.70 39.70 39.70 0.00 H Red blood cell concentration measurement (85014) Yes 39.70 39.70 39.70 0.00 H Red blood cell concentration measurement (85014) Yes 39.70 39.70 39.70 0.00 H Red blood cell concentration measurement (85014) Yes 59.55 59.55 59.55 0.00 H Red blood cell concentration measurement (85014) Yes 39.70 39.70 39.70 0.00 H Red blood cell concentration measurement (85014) Yes 39.70 39.70 39.70 0.00 H Hemoglobin measurement (85018) Yes 12.78 12.78 12.78 0.00 H Hemoglobin measurement (85018) Yes 38.34 38.34 38.34 0.00 H Hemoglobin measurement (85018) Yes 25.56 25.56 25.56 0.00 H Hemoglobin measurement (85018) Yes 25.56 25.56 25.56 0.00 H Hemoglobin measurement (85018) Yes 25.56 25.56 25.56 0.00 H Hemoglobin measurement (85018) Yes 25.56 25.56 25.56 0.00 H Hemoglobin measurement (85018) Yes 38.34 38.34 38.34 0.00 H Hemoglobin measurement (85018) Yes 25.56 25.56 25.56 0.00 H Hemoglobin measurement (85018) Yes 25.56 25.56 25.56 0.00 H Heparin assay (85520) Yes 1,188.50 1,188.50 1,188.50 0.00 H Coagulation assessment blood test (85730) Yes 54.02 54.02 54.02 0.00 H Coagulation assessment blood test (85730) Yes 54.02 54.02 54.02 0.00 H Coagulation assessment blood test (85730) Yes 54.02 54.02 54.02 0.00 H Claim #21035000422104NYA (continued) Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington Ocboter 20 – November 23, 2011/The New York and Presbyterian Hospital continued... Continued Notes for Claims Above I This service is paid at 100% of the Medicare approved amount. Service Provided & Billing Code Service Approved? Amount Facility Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Coagulation assessment blood test (85730) Yes 54.02 54.02 54.02 0.00 I Coagulation assessment blood test (85730) Yes 54.02 54.02 54.02 0.00 I Coagulation assessment blood test (85730) Yes 54.02 54.02 54.02 0.00 I Coagulation assessment blood test (85730) Yes 54.02 54.02 54.02 0.00 I Coagulation assessment blood test (85730) Yes 54.02 54.02 54.02 0.00 I Coagulation assessment blood test (85730) Yes 54.02 54.02 54.02 0.00 I Coagulation assessment blood test (85730) Yes 108.04 108.04 108.04 0.00 I Coagulation assessment blood test (85730) Yes 108.04 108.04 108.04 0.00 I Coagulation assessment blood test (85730) Yes 108.04 108.04 108.04 0.00 I Coagulation assessment blood test (85730) Yes 108.04 108.04 108.04 0.00 I Coagulation assessment blood test (85730) Yes 108.04 108.04 108.04 0.00 I Coagulation assessment blood test (85730) Yes 108.04 108.04 108.04 0.00 I Coagulation assessment blood test (85730) Yes 108.04 108.04 108.04 0.00 I Coagulation assessment blood test (85730) Yes 108.04 108.04 108.04 0.00 I Coagulation assessment blood test (85730) Yes 108.04 108.04 108.04 0.00 I Coagulation assessment blood test (85730) Yes 108.04 108.04 108.04 0.00 I Blood group typing (ABO) (86900) Yes 24.00 24.00 24.00 2.60 Blood group typing (ABO) (86900) Yes 24.00 24.00 24.00 2.60 Blood group typing (ABO) (86900) Yes 24.00 24.00 24.00 2.60 Claim #21035000422104NYA (continued) Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington THIS IS NOT A BILL | Page 9 of 26 Ocboter 20 – November 23, 2011/The New York and Presbyterian Hospital continued... Service Provided & Billing Code Service Approved? Amount Facility Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Blood group typing (ABO) (86900) Yes 24.00 24.00 24.00 2.60 Blood group typing (ABO) (86900) Yes 24.00 24.00 24.00 2.60 Stool culture (87046) Yes 50.72 50.72 50.72 0.00 J Bacterial culture (87070) Yes 108.05 108.05 108.05 0.00 J Screening test for pathogenic organisms (87081) Yes 72.77 72.77 72.77 0.00 J Screening test for pathogenic organisms (87081) Yes 72.77 72.77 72.77 0.00 K Screening test for pathogenic organisms (87081) Yes 72.77 72.77 72.77 0.00 J Screening test for pathogenic organisms (87081) Yes 72.77 72.77 72.77 0.00 J Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral) (87081) Yes 62.84 62.84 62.84 0.00 J Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral) (87081) Yes 62.84 62.84 62.84 0.00 J Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral) (87081) Yes 62.84 62.84 62.84 0.00 J Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral) (87081) Yes 125.68 125.68 125.68 0.00 J Special stain for microorganism (87205) Yes 88.20 88.20 88.20 0.00 J Special stain for microorganism (87205) Yes 264.60 264.60 264.60 0.00 J Special stain for microorganism (87205) Yes 176.40 176.40 176.40 0.00 J Special stain for microorganism (87205) Yes 176.40 176.40 176.40 0.00 J Claim #21035000422104NYA (continued) Continued Notes for Claims Above J This service is paid at 100% of the Medicare approved amount. K This item or service cannot be paid as billed. Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington THIS IS NOT A BILL | Page 10 of 26 Ocboter 20 – November 23, 2011/The New York and Presbyterian Hospital continued... Service Provided & Billing Code Item Approved? Amount Facility Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Special stain for microorganism (87205) Yes 352.80 352.80 352.80 0.00 L Tissue culture innoculation for virus isolation (87252) Yes 243.65 243.65 243.65 0.00 L Detection test for Adenovirus (virus) (87260) Yes 39.69 39.69 39.69 0.00 L Detection test for Parainfluenza virus (87279) Yes 119.07 119.07 119.07 0.00 L Detection test for Varicella (chicken pox) zoster virus (87290) Yes 70.38 70.38 70.38 0.00 L Immunologic analysis for detection of organism (87449) Yes 156.56 156.56 156.56 0.00 L Immunologic analysis for detection of organism (87449) Yes 156.56 156.56 156.56 0.00 L Detection test for; cytomegalovirus, quantification (87497) Yes 574.40 574.40 574.40 0.00 L Detection test for; cytomegalovirus, quantification (87497) Yes 574.40 574.40 574.40 0.00 L Detection test for; cytomegalovirus, quantification (87497) Yes 574.40 574.40 574.40 0.00 L Detection test for; cytomegalovirus, quantification (87497) Yes 574.40 574.40 574.40 0.00 L Detection test for; cytomegalovirus, quantification (87497) Yes 574.40 574.40 574.40 0.00 L Detection test for; cytomegalovirus, quantification (87497) Yes 574.40 574.40 574.40 0.00 L Blood test, basic group of blood chemicals (80048) Yes 60.64 60.64 60.64 0.00 L Blood test, basic group of blood chemicals (80048) Yes 60.64 60.64 60.64 0.00 L Blood test, basic group of blood chemicals (80048) Yes 60.64 60.64 60.64 0.00 L Blood test, basic group of blood chemicals (80048) Yes 60.64 60.64 60.64 0.00 L Claim #21035000422104NYA (continued) Continued Notes for Claims Above L This service is paid at 100% of the Medicare approved amount. Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington THIS IS NOT A BILL | Page 11 of 26 Ocboter 20 – November 23, 2011/The New York and Presbyterian Hospital continued... Service Provided & Billing Code Service Approved? Amount Facility Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Blood test, basic group of blood chemicals (80048) Yes 60.64 60.64 60.64 0.00 M Blood test, basic group of blood chemicals (80048) Yes 60.64 60.64 60.64 0.00 M Blood test, basic group of blood chemicals (80048) Yes 60.64 60.64 60.64 0.00 M Blood test, basic group of blood chemicals (80048) Yes 60.64 60.64 60.64 0.00 M Blood test, basic group of blood chemicals (80048) Yes 60.64 60.64 60.64 0.00 M Blood test, basic group of blood chemicals (80048) Yes 60.64 60.64 60.64 0.00 M Blood test, basic group of blood chemicals (80048) Yes 60.64 60.64 60.64 0.00 M Blood test, basic group of blood chemicals (80048) Yes 60.64 60.64 60.64 0.00 M Blood test, basic group of blood chemicals (80048) Yes 60.64 60.64 60.64 0.00 M Blood test, basic group of blood chemicals (80048) Yes 60.64 60.64 60.64 0.00 M Blood test, basic group of blood chemicals (80048) Yes 60.64 60.64 60.64 0.00 M Blood test, basic group of blood chemicals (80048) Yes 181.92 181.92 181.92 0.00 M Blood test, basic group of blood chemicals (80048) Yes 181.92 181.92 181.92 0.00 M Blood test, basic group of blood chemicals (80048) Yes 181.92 181.92 181.92 0.00 M Blood test, basic group of blood chemicals (80048) Yes 121.28 121.28 121.28 0.00 M Blood test, basic group of blood chemicals (80048) Yes 121.28 121.28 121.28 0.00 M Blood test, basic group of blood chemicals (80048) Yes 121.28 121.28 121.28 0.00 M Claim #21035000422104NYA (continued) Continued Notes for Claims Above M This service is paid at 100% of the Medicare approved amount. Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington THIS IS NOT A BILL | Page 12 of 26 Ocboter 20 – November 23, 2011/The New York and Presbyterian Hospital continued... Service Provided & Billing Code Service Approved? Amount Facility Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Blood test, basic group of blood chemicals (80048) Yes 121.28 121.28 121.28 0.00 N Blood test, basic group of blood chemicals (80048) Yes 121.28 121.28 121.28 0.00 N Blood test, basic group of blood chemicals (80048) Yes 121.28 121.28 121.28 0.00 N Blood test, basic group of blood chemicals (80048) Yes 121.28 121.28 121.28 0.00 N Blood test, basic group of blood chemicals (80048) Yes 121.28 121.28 121.28 0.00 N Blood test, basic group of blood chemicals (80048) Yes 121.28 121.28 121.28 0.00 N Blood test, basic group of blood chemicals (80048) Yes 121.28 121.28 121.28 0.00 N Blood test, basic group of blood chemicals (80048) Yes 121.28 121.28 121.28 0.00 N Blood test, basic group of blood chemicals (80048) Yes 181.92 181.92 181.92 0.00 N Blood test, basic group of blood chemicals (80048) Yes 121.28 121.28 121.28 0.00 N Blood test, basic group of blood chemicals (80048) Yes 121.28 121.28 121.28 0.00 N Blood test, basic group of blood chemicals (80048) Yes 121.28 121.28 121.28 0.00 N Alcohol (ethanol) level (82055) Yes 116.87 116.87 116.87 0.00 N Ammonia level (82140) Yes 72.77 72.77 72.77 0.00 N Ammonia level (82140) Yes 72.77 72.77 72.77 0.00 N Amylase (enzyme) level (82150) Yes 51.82 51.82 51.82 0.00 N Calcium level (82330) Yes 193.05 193.05 193.05 0.00 N,O Calcium level (82330) Yes 579.15 579.15 579.15 0.00 N,O Calcium level (82330) Yes 386.10 386.10 386.10 0.00 N,O Claim #21035000422104NYA (continued) Continued Notes for Claims Above N This service is paid at 100% of the Medicare approved amount. O 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 # L28209. Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington THIS IS NOT A BILL | Page 13 of 26 Ocboter 20 – November 23, 2011/The New York and Presbyterian Hospital continued... Service Provided & Billing Code Service Approved? Amount Facility Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Calcium level (82330) Yes 386.10 386.10 386.10 0.00 P,Q Calcium level (82330) Yes 386.10 386.10 386.10 0.00 P,Q Calcium level (82330) Yes 386.10 386.10 386.10 0.00 P,Q Calcium level (82330) Yes 579.15 579.15 579.15 0.00 P,Q Calcium level (82330) Yes 386.10 386.10 386.10 0.00 P,Q Calcium level (82330) Yes 386.10 386.10 386.10 0.00 P,Q Creatinine level to test for kidney function or muscle injury (82570) Yes 123.48 123.48 123.48 0.00 P Creatinine level to test for kidney function or muscle injury (82570) Yes 123.48 123.48 123.48 0.00 P Creatinine level to test for kidney function or muscle injury (82570) Yes 123.48 123.48 123.48 0.00 P Cyanocobalamin (vitamin B-12) level (82607) Yes 108.05 108.05 108.05 0.00 P Cyanocobalamin (vitamin B-12) level (82607) Yes 108.05 108.05 108.05 0.00 P Folic acid level (82746) Yes 144.43 144.43 144.43 0.00 P Folic acid level (82746) Yes 144.43 144.43 144.43 0.00 P Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 28.00 28.00 28.00 0.00 P Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 28.00 28.00 28.00 0.00 P Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 196.00 196.00 196.00 0.00 P Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 252.00 252.00 252.00 0.00 P Claim #21035000422104NYA (continued) Continued Notes for Claims Above P This service is paid at 100% of the Medicare approved amount. P Q 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 # L28209. Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington Ocboter 20 – November 23, 2011/The New York and Presbyterian Hospital continued... Service Provided & Billing Code Service Approved? Amount Facility Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 252.00 252.00 252.00 0.00 R Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 308.00 308.00 308.00 0.00 R Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 308.00 308.00 308.00 0.00 R Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 308.00 308.00 308.00 0.00 R Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 308.00 308.00 308.00 0.00 R Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 252.00 252.00 252.00 0.00 R Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 308.00 308.00 308.00 0.00 R Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 364.00 364.00 364.00 0.00 R Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 84.00 84.00 84.00 0.00 R Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 84.00 84.00 84.00 0.00 R Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 140.00 140.00 140.00 0.00 R Claim #21035000422104NYA (continued) Continued Notes for Claims Above R This service is paid at 100% of the Medicare approved amount. Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington THIS IS NOT A BILL | Page 15 of 26 Ocboter 20 – November 23, 2011/The New York and Presbyterian Hospital continued... Service Provided & Billing Code Service Approved? Amount Facility Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 112.00 112.00 112.00 0.00 S Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 84.00 84.00 84.00 0.00 S Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 112.00 112.00 112.00 0.00 S Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 56.00 56.00 56.00 0.00 S Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 112.00 112.00 112.00 0.00 S Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 112.00 112.00 112.00 0.00 S Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 112.00 112.00 112.00 0.00 S Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 336.00 336.00 336.00 0.00 S Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 336.00 336.00 336.00 0.00 S Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 308.00 308.00 308.00 0.00 S Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 196.00 196.00 196.00 0.00 S Claim #21035000422104NYA (continued) Continued Notes for Claims Above S This service is paid at 100% of the Medicare approved amount. Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington THIS IS NOT A BILL | Page 16 of 26 Ocboter 20 – November 23, 2011/The New York and Presbyterian Hospital continued... Continued Notes for Claims Above T This service is paid at 100% of the Medicare approved amount. Service Provided & Billing Code Service Approved? Amount Facility Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 308.00 308.00 308.00 0.00 T Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 280.00 280.00 280.00 0.00 T Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 280.00 280.00 280.00 0.00 T Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 336.00 336.00 336.00 0.00 T Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 364.00 364.00 364.00 0.00 T Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 308.00 308.00 308.00 0.00 T Blood glucose (sugar) test performed by hand-held instrument (92962) Yes 140.00 140.00 140.00 0.00 T Glutamyltransferase (liver enzyme) level (82977) Yes 88.20 88.20 88.20 0.00 T Glutamyltransferase (liver enzyme) level (82977) Yes 88.20 88.20 88.20 0.00 T Glutamyltransferase (liver enzyme) level (82977) Yes 88.20 88.20 88.20 0.00 T Glutamyltransferase (liver enzyme) level (82977) Yes 88.20 88.20 88.20 0.00 T Glutamyltransferase (liver enzyme) level (82977) Yes 88.20 88.20 88.20 0.00 T Haptoglobin (serum protein) level (83010) Yes 76.07 76.07 76.07 0.00 T Lactic acid level (83605) Yes 184.12 184.12 184.12 0.00 T Lactic acid level (83605) Yes 184.12 184.12 184.12 0.00 T Claim #21035000422104NYA (continued) Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington THIS IS NOT A BILL | Page 17 of 26 Ocboter 20 – November 23, 2011/The New York and Presbyterian Hospital continued... Service Provided & Billing Code Service Approved? Amount Facility Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Lactic acid level (83605) Yes 184.12 184.12 184.12 0.00 U Lactic acid level (83605) Yes 184.12 184.12 184.12 0.00 U Lactic acid level (83605) Yes 184.12 184.12 184.12 0.00 U Lactic acid level (83605) Yes 184.12 184.12 184.12 0.00 U Lactic acid level (83605) Yes 184.12 184.12 184.12 0.00 U Lactic acid level (83605) Yes 184.12 184.12 184.12 0.00 U Lactic acid level (83605) Yes 184.12 184.12 184.12 0.00 U Lactic acid level (83605) Yes 184.12 184.12 184.12 0.00 U Lactic acid level (83605) Yes 184.12 184.12 184.12 0.00 U Lactic acid level (83605) Yes 184.12 184.12 184.12 0.00 U Lactate dehydrogenase (enzyme) level (83615) Yes 69.46 69.46 69.46 0.00 U Lipase (fat enzyme) level (83690) Yes 38.59 38.59 38.59 0.00 U Magnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,W Magnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,W Magnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,W Magnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,W Magnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,W Magnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,W Magnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,W Magnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,W Magnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,W Magnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,W Magnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,W Magnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,W Magnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,W Magnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,W Magnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,W Magnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,W Magnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,W Magnesium level (83735) Yes 291.06 291.06 291.06 0.00 U,W Claim #21035000422104NYA (continued) Continued Notes for Claims Above U This service is paid at 100% of the Medicare approved amount. W 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. Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington THIS IS NOT A BILL | Page 18 of 26 Ocboter 20 – November 23, 2011/The New York and Presbyterian Hospital continued... Service Provided & Billing Code Service Approved? Amount Facility Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Magnesium level (83735) Yes 291.06 291.06 291.06 0.00 X,Y Magnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,Y Magnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,Y Magnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,Y Magnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,Y Magnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,Y Magnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,Y Magnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,Y Magnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,Y Magnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,Y Magnesium level (83735) Yes 291.06 291.06 291.06 0.00 X,Y Magnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,Y Magnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,Y Magnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,Y Phosphate level (84100) Yes 72.77 72.77 72.77 0.00 X Phosphate level (84100) Yes 72.77 72.77 72.77 0.00 X Phosphate level (84100) Yes 72.77 72.77 72.77 0.00 X Phosphate level (84100) Yes 72.77 72.77 72.77 0.00 X Phosphate level (84100) Yes 72.77 72.77 72.77 0.00 X Phosphate level (84100) Yes 72.77 72.77 72.77 0.00 X Phosphate level (84100) Yes 72.77 72.77 72.77 0.00 X Phosphate level (84100) Yes 72.77 72.77 72.77 0.00 X Phosphate level (84100) Yes 72.77 72.77 72.77 0.00 X Phosphate level (84100) Yes 72.77 72.77 72.77 0.00 X Phosphate level (84100) Yes 72.77 72.77 72.77 0.00 X Phosphate level (84100) Yes 72.77 72.77 72.77 0.00 X Phosphate level (84100) Yes 72.77 72.77 72.77 0.00 X Phosphate level (84100) Yes 72.77 72.77 72.77 0.00 X Phosphate level (84100) Yes 72.77 72.77 72.77 0.00 X Claim #21035000422104NYA (continued) Continued Notes for Claims Above X This service is paid at 100% of the Medicare approved amount. Y 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. Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington THIS IS NOT A BILL | Page 19 of 26 Ocboter 20 – November 23, 2011/The New York and Presbyterian Hospital continued... Service Provided & Billing Code Service Approved? Amount Facility Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Phosphate level (84100) Yes 72.77 72.77 0.00 0.00 Z Phosphate level (84100) Yes 218.31 218.31 0.00 0.00 Z Phosphate level (84100) Yes 218.31 218.31 0.00 0.00 Z Phosphate level (84100) Yes 145.54 145.54 0.00 0.00 Z Phosphate level (84100) Yes 145.54 145.54 0.00 0.00 Z Phosphate level (84100) Yes 145.54 145.54 0.00 0.00 Z Phosphate level (84100) Yes 145.54 145.54 0.00 0.00 Z Phosphate level (84100) Yes 145.54 145.54 0.00 0.00 Z Phosphate level (84100) Yes 145.54 145.54 0.00 0.00 Z Phosphate level (84100) Yes 145.54 145.54 0.00 0.00 Z Phosphate level (84100) Yes 145.54 145.54 0.00 0.00 Z Phosphate level (84100) Yes 145.54 145.54 0.00 0.00 Z Phosphate level (84100) Yes 218.31 218.31 0.00 0.00 Z Phosphate level (84100) Yes 145.54 145.54 0.00 0.00 Z Phosphate level (84100) Yes 145.54 145.54 0.00 0.00 Z Phosphate level (84100) Yes 145.54 145.54 0.00 0.00 Z Urine potassium level (84133) Yes 34.18 34.18 0.00 0.00 Z Urine potassium level (84133) Yes 34.18 34.18 0.00 0.00 Z Urine sodium level (84300) Yes 31.97 31.97 0.00 0.00 Z Urine sodium level (84300) Yes 31.97 31.97 0.00 0.00 Z Urine sodium level (84300) Yes 31.97 31.97 0.00 0.00 Z Blood test, thyroid stimulating hormone (TSH) (84443) Yes 153.80 153.80 0.00 0.00 Z Troponin (protein) analysis (84484) Yes 183.02 183.02 0.00 0.00 Z Troponin (protein) analysis (84484) Yes 183.02 183.02 0.00 0.00 Z Troponin (protein) analysis (84484) Yes 83.02 83.02 0.00 0.00 Z Troponin (protein) analysis (84484) Yes 83.02 83.02 0.00 0.00 Z Troponin (protein) analysis (84484) Yes 83.02 83.02 0.00 0.00 Z Urea nitrogen level to assess kidney function (84540) Yes 169.79 169.79 0.00 0.00 Z Syphilis detection test (86592) Yes 73.87 73.87 0.00 0.00 Z Detection test for Influenza virus, A or B (87400) Yes 140.76 140.76 0.00 0.00 Z Claim #21035000422104NYA (continued) Continued Notes for Claims Above Z This service is paid at 100% of the Medicare approved amount. Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington THIS IS NOT A BILL | Page 20 of 26 Ocboter 20 – November 23, 2011/The New York and Presbyterian Hospital continued... Service Provided & Billing Code Service Approved? Amount Facility Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Complete blood cell count (red cells, white blood cell, platelets), automated test (85025) Yes 48.51 48.51 0.00 0.00 a Complete blood cell count (red cells, white blood cell, platelets), automated test (85025) Yes 97.02 97.02 0.00 0.00 a Complete blood cell count (red cells, white blood cell, platelets), automated test (85025) Yes 97.02 97.02 0.00 0.00 a Complete blood cell count (red cells, white blood cell, platelets), automated test (85025) Yes 97.02 97.02 0.00 0.00 a Complete blood cell count (red cells, white blood cell, platelets), automated test (85025) Yes 97.02 97.02 0.00 0.00 a Complete blood cell count (red cells, white blood cell, platelets), automated test (85025) Yes 97.02 97.02 0.00 0.00 a Complete blood cell count (red cells, white blood cell, platelets), automated test (85025) Yes 97.02 97.02 0.00 0.00 a Complete blood cell count (red cells, white blood cell, platelets), automated test (85025) Yes 97.02 97.02 0.00 0.00 a Complete blood cell count (red cells, white blood cell, platelets), automated test (85027) Yes 37.11 37.11 0.00 0.00 b Complete blood cell count (red cells, white blood cell, platelets), automated test (85027) Yes 37.11 37.11 0.00 0.00 a Complete blood cell count (red cells, white blood cell, platelets), automated test (85027) Yes 37.11 37.11 0.00 0.00 a Claim #21035000422104NYA (continued) Continued Notes for Claims Above a This service is paid at 100% of the Medicare approved amount. b This item or service cannot be paid as billed. Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington THIS IS NOT A BILL | Page 21 of 26 Ocboter 20 – November 23, 2011/The New York and Presbyterian Hospital continued... Service Provided & Billing Code Service Approved? Amount Facility Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Complete blood cell count (red cells, white blood cell, platelets), automated test (85027) Yes 37.11 37.11 0.00 0.00 c Complete blood cell count (red cells, white blood cell, platelets), automated test (85027) Yes 37.11 37.11 0.00 0.00 c Complete blood cell count (red cells, white blood cell, platelets), automated test (85027) Yes 37.11 37.11 0.00 0.00 c Complete blood cell count (red cells, white blood cell, platelets), automated test (85027) Yes 37.11 37.11 0.00 0.00 c Complete blood cell count (red cells, white blood cell, platelets), automated test (85027) Yes 74.22 74.22 0.00 0.00 c Complete blood cell count (red cells, white blood cell, platelets), automated test (85027) Yes 74.22 74.22 0.00 0.00 c Complete blood cell count (red cells, white blood cell, platelets), automated test (85027) Yes 111.33 111.33 0.00 0.00 c Complete blood cell count (red cells, white blood cell, platelets), automated test (85027) Yes 74.22 74.22 0.00 0.00 c Complete blood cell count (red cells, white blood cell, platelets), automated test (85027) Yes 74.22 74.22 0.00 0.00 c Complete blood cell count (red cells, white blood cell, platelets), automated test (85027) Yes 111.33 111.33 0.00 0.00 c Complete blood cell count (red cells, white blood cell, platelets), automated test (85027) Yes 111.33 111.33 0.00 0.00 c Claim #21035000422104NYA (continued) Continued Notes for Claims Above c This service is paid at 100% of the Medicare approved amount. Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington THIS IS NOT A BILL | Page 22 of 26 Ocboter 20 – November 23, 2011/The New York and Presbyterian Hospital continued... Service Provided & Billing Code Service Approved? Amount Facility Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Coagulation function measurement (85379) Yes 136.71 136.71 0.00 0.00 d Coagulation function measurement (85379) Yes 136.71 136.71 0.00 0.00 d Coagulation function measurement (85379) Yes 136.71 136.71 0.00 0.00 d Fibrinogen (Factor 1) antigen detection (85385) Yes 44.10 44.10 0.00 0.00 d Fibrinogen (Factor 1) antigen detection (85385) Yes 44.10 44.10 0.00 0.00 d Fibrinogen (Factor 1) antigen detection (85385) Yes 44.10 44.10 0.00 0.00 d Fibrinogen (Factor 1) antigen detection (85385) Yes 44.10 44.10 0.00 0.00 d Fibrinogen (Factor 1) antigen detection (85385) Yes 88.20 88.20 0.00 0.00 d Fibrinogen (Factor 1) antigen detection (85385) Yes 88.20 88.20 0.00 0.00 d Blood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 d Blood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 d Blood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 d Blood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 d Blood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 d Blood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 d Blood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 d Blood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 d Blood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 d Blood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 d Blood test, clotting time (85610) Yes 74.98 74.98 0.00 0.00 d Blood test, clotting time (85610) Yes 74.98 74.98 0.00 0.00 d Blood test, clotting time (85610) Yes 74.98 74.98 0.00 0.00 d Blood test, clotting time (85610) Yes 74.98 74.98 0.00 0.00 d Blood test, clotting time (85610) Yes 74.98 74.98 0.00 0.00 d Blood test, clotting time (85610) Yes 74.98 74.98 0.00 0.00 d Claim #21035000422104NYA (continued) Continued Notes for Claims Above d This service is paid at 100% of the Medicare approved amount. Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington THIS IS NOT A BILL | Page 23 of 26 Ocboter 20 – November 23, 2011/The New York and Presbyterian Hospital continued... Service Provided & Billing Code Service Approved? Amount Facility Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Bacterial blood culture (87040) Yes 131.13 131.13 131.13 0.00 e Bacterial blood culture (87040) Yes 232.26 232.26 232.26 0.00 f Bacterial blood culture (87040) Yes 232.26 232.26 232.26 0.00 f Bacterial blood culture (87040) Yes 232.26 232.26 232.26 0.00 f Stool culture (87045) Yes 91.51 91.51 91.51 0.00 f Bacterial culture (87070) Yes 108.05 108.05 108.05 0.00 f Bacterial culture (87070) Yes 108.05 108.05 108.05 0.00 f Bacterial culture (87070) Yes 108.05 108.05 108.05 0.00 f Bacterial culture and colony count for anaerobic bacteria (87073) Yes 121.25 121.25 121.25 0.00 f Bacterial urine culture (87088) Yes 34.18 34.18 34.18 0.00 f Bacterial urine culture (87088) Yes 34.18 34.18 34.18 0.00 f Bacterial urine culture (87088) Yes 68.36 68.36 68.36 0.00 f Fungal blood culture (mold or yeast) (87103) Yes 113.93 113.93 113.93 0.00 f Smear for parasites (87177) Yes 104.74 104.74 104.74 0.00 f Immunologic analysis for detection of organism (87449) Yes 156.56 156.56 156.56 0.00 f Immunologic analysis for detection of organism (87449) Yes 156.56 156.56 156.56 0.00 f Detection test for organism (87798) Yes 511.56 511.56 511.56 0.00 f Detection test for organism (87798) Yes 1,534.68 1,534.68 1,534.68 0.00 f Special stained specimen slides to identify organisms (88312) Yes 166.48 166.48 166.48 6.10 Cell examination of specimen (88112) Yes 155.45 155.45 155.45 12.79 Special stain for parasites (87209) Yes 69.46 69.46 69.46 0.00 f Pathology examination of tissue using a microscope, moderately high complexity (88307) Yes 339.57 339.57 339.57 18.47 Special stained specimen slides to identify organisms (88312) Yes 998.88 998.88 998.88 36.60 Claim #21035000422104NYA (continued) Continued Notes for Claims Above e This service is paid at 100% of the Medicare approved amount. f This item or service cannot be paid as billed. Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington THIS IS NOT A BILL | Page 24 of 26 Ocboter 20 – November 23, 2011/The New York and Presbyterian Hospital continued... Service Provided & Billing Code Service Approved? Amount Facility Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Tissue or cell analysis by immunologic technique (88342) Yes 255.78 255.78 255.78 0.00 g,h Xray of abdomen, single view (74000) Yes 213.06 213.06 213.06 10.55 Xray of abdomen, single view (74000) Yes 213.06 213.06 213.06 10.55 Xray of abdomen, single view (74000) Yes 213.06 213.06 213.06 10.55 Xray of chest, 1 view, front (71010) Yes 667.01 667.01 667.01 21.09 Xray of chest, 1 view, front (71010) Yes 1,124.55 1,124.55 1,124.55 31.64 Xray of chest, 1 view, front (71010) Yes 374.85 374.85 374.85 10.55 Xray of chest, 1 view, front (71010) Yes 374.85 374.85 374.85 10.55 Xray of chest, 1 view, front (71010) Yes 374.85 374.85 374.85 10.55 Xray of chest, 1 view, front (71010) Yes 374.85 374.85 374.85 10.55 Xray of chest, 1 view, front (71010) Yes 374.85 374.85 374.85 10.55 Xray of chest, 1 view, front (71010) Yes 374.85 374.85 374.85 10.55 Total for Claim #21035000422104NYA $63,960.35 $63,960.35 $63,960.35 $234.64 Notes for Claims Above g Medicare cannot pay for this service for the diagnosis shown on the claim. h You should not be billed for this service. You are only responsible for any deductible and coinsurance amounts listed in the ‘Maximum You May Be Billed’ column. Continued Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health Jennifer Washington THIS IS NOT A BILL | Page 25 of 26 Your Home Health Claims for Part A (Hospital Insurance) Notes for Claims Above i What Medicare pays for a service or item may be higher than the billed amount. The Medicare payment amount is correct. Medicare pays this provider less than the billed amount on other claims since payment rates are set in advance for certain services and averaged out over an entire year. Quantity & Service Provided Service Approved? Amount Provider Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below 6 Physical Therpy Yes $1,200.00 $2,093.37 $2,093.37 $0.00 1 Occupation Therapy Yes 200.00 200.00 200.00 0.00 4 Skilled Nursing Yes 720.00 920.00 920.00 0.00 Total for Claim #20022000001804NYR $2,120.00 $3,213.37 $3,213.37 $0.00 i Part A 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 Service Approved?: This column tells you if Medicare covered the home health 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 the 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. This is usually $0. For durable medical equipment, it can include 20% of the Medicare-approved amount. If you have Medicare Supplement Insurance (Medigap policy) or other insurance, it may pay all or part of this amount. September 10 – October 20, 2011 Heartland Home Health Care, (555) 555-1234 4855 W Hillsboro Blvd, Suite B-4, Coconut Creek, FL 33073-4356 Referred by Marta Lacayo Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health 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 26 of 26 How to Handle Denied Claims or File an Appeal Exhibit 2.11 – Combined Claims, Part A Inpatient, B of A and Home Health