Medicare Summary Notices - English Exhibits - 2.12_Combined_PartB_120907.pdf

Page 1 of 8 Medicare Summary Notice for 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 for most health services before Medicare begins to pay. Part B Deductible: You have now 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 Your Claims & Costs This Period Did Medicare Approve All Services? NO Number of Services Medicare Denied 2 See claims starting on page 3. Look for NO in the “Service Approved?” column. See the last page for how to handle a denied claim. Total You May Be Billed $27.30 Providers with Claims This Period June 18 – 20, 2011 Susan Jones, M.D. June 9 – June 24, 2011 Behavioral Medicine Ins ¿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 2.12 – Combined Claims, Part B Assigned and Unassigned THIS IS NOT A BILL | Page 2 of 8 Jennifer Washington Making the Most of Your Medicare  How to Check This Notice Do you recognize the name of each doctor or provider? Check the dates. Did you have an appointment that day? Did you get the 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 provider 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 “doctors 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. Medicare Preventive Services Medicare covers many free or low-cost exams and screenings to help you stay healthy. For more information about preventive services: • Talk to your doctor. • Look at your “Medicare & You” handbook for a complete list. • Visit www.MyMedicare.gov for a personalized list. Exhibit 2.12 – Combined Claims, Part B Assigned and Unassigned Jennifer Washington THIS IS NOT A BILL | Page 3 of 8 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) Service Provided & Billing Code Service 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 minut (97110) Yes $45.00 $28.54 $22.83 $5.71 Total for Claim #02-10195-592-677 $45.00 $28.54 $22.83 $5.71 A June 18, 2011 Dr. Susan Jones, M.D., (555) 555-1234 Brevard County Physical Therapy Center, 32 Main Street, Brevard, NC 28712-4187 Continued Notes for Claims Above A 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 2.12 – Combined Claims, Part B Assigned and Unassigned Service Provided & Billing Code Service Approved? Amount Provider Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Eye and medical examination for diagnosis and treatment, established patient, 1 or more visits (92014) Yes $143.00 $107.97 $86.38 $21.59 Computerized mapping of corneal curvature (92025) Yes 0.00 0.00 0.00 0.00 B Total for Claim #02-10195-592-990 $143.00 $107.97 $86.38 $21.59 C Jennifer Washington THIS IS NOT A BILL | Page 4 of 8 June 20, 2011 Dr. Susan Jones, M.D., (555) 555-1234 Brevard County Physical Therapy Center, 32 Main Street, Brevard, NC 28712-4187 Notes for Claims Above B This line is for reporting purposes only. You should not be charged. If there is a fee listed, you do not have to pay. 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. Continued Exhibit 2.12 – Combined Claims, Part B Assigned and Unassigned Service Provided & Billing Code Service Approved? Amount Provider Charged Medicare- Approved Amount Medicare Paid You Maximum You May Be Billed See Notes Below June 9, 2011 Psychiatric interview for diagnosis (90801-59) Yes $500.00 $150.33 $120.26 $0.00 D,E Psychological testing (90830) NO 250.00 0.00 0.00 0.00 F Claim #46-10326-262-000 (continued) Jennifer Washington THIS IS NOT A BILL | Page 5 of 8 June 9 – June 24, 2011 Behavioral Medicine Ins, (555) 555-1234 1401 Pchtree NE St #140, Atlanta, GA 30309-3000 Medicare claims may be assigned or unassigned. Your claims below are unassigned—meaning the provider hasn’t agreed to accept the Medicare-approved amount as payment in full. Do Unassigned Claims Cost More? Maybe. A provider who doesn’t accept assignment may charge you up to 15% over the Medicare-approved amount. This is known as the limiting charge. You may have to pay this amount, or it may be covered by another insurer. For a list of providers that always accept Medicare assignment, visit www.medicare.gov/provider or call 1-800-MEDICARE (1-800-633-4227). You may save money by choosing providers who accept assignment. Definitions of Columns Service Approved?: This column tells you if Medicare covered the 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. Since your provider hasn’t agreed to accept assignment, you might be charged up to 15% more than this amount. Medicare usually pays 80% of the Medicare-approved amount. Medicare Paid You: When a provider doesn’t accept assignment, Medicare pays you directly. You’ll usually get 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. Continued Notes for Claims Above D The approved amount is based on a special payment method. E The previous notice we sent stated the amount you could be charged for this service. This additional payment changed that amount. Your doctor cannot charge you more than $172.88. F This item or service was denied because information required to make payment was incorrect. Your Unassigned Claims for Part B (Medical Insurance) Exhibit 2.12 – Combined Claims, Part B Assigned and Unassigned Service Provided & Billing Code Service Approved? Amount Provider Charged Medicare- Approved Amount Medicare Paid You Maximum You May Be Billed See Notes Below Psychiatric evaluation of hospital records, reports, testing, or data for diagnosis (90885) Yes 250.00 0.00 0.00 0.00 G,H,I, J Family psychotherapy not including patient (90846) Yes 425.00 84.62 46.54 0.00 K,L,M Psychiatric interview for diagnosis (90801-59) Yes 500.00 150.33 120.26 0.00 K,N Psychiatric interview for diagnosis (90801-59) Yes 500.00 150.33 120.26 0.00 K,N Psychiatric interview for diagnosis (90801-59) Yes 500.00 150.33 120.26 0.00 K,N Psychological testing (96100) NO 250.00 0.00 0.00 0.00 O Individual office or outpatient psychotherapy, approximately 45 to 50 minutes (90806) Yes 250.00 90.34 49.69 0.00 K,L,P Individual office or outpatient psychotherapy, approximately 45 to 50 minutes (90806) Yes 175.00 90.34 49.69 0.00 K,L,P Claim #46-10326-262-000 (continued) Jennifer Washington THIS IS NOT A BILL | Page 6 of 8 June 9 – June 24, 2011/Behavioral Medicine Ins continued... Continued Notes for Claims Above G Payment is included in another service received on the same day. H Medicare does not pay separately for this service. I You do not have to pay this amount. J The previous notice we sent stated the amount you could be charged for this service. This additional payment changed that amount. Your doctor cannot charge you more than $0.00. K The approved amount is based on a special payment method. L Outpatient mental health services are paid at 55% of the approved amount. M The previous notice we sent stated the amount you could be charged for this service. This additional payment changed that amount. Your doctor cannot charge you more than $97.31. N The previous notice we sent stated the amount you could be charged for this service. This additional payment changed that amount. Your doctor cannot charge you more than $172.88. O This item or service was denied because information required to make payment was incorrect. P The previous notice we sent stated the amount you could be charged for this service. This additional payment changed that amount. Your doctor cannot charge you more than $103.89. Exhibit 2.12 – Combined Claims, Part B Assigned and Unassigned Service Provided & Billing Code Service Approved? Amount Provider Charged Medicare- Approved Amount Medicare Paid You Maximum You May Be Billed See Notes Below Individual office or outpatient psychotherapy, approximately 45 to 50 minutes (90806) Yes 200.00 90.34 49.69 0.00 Q,R,S June 16, 2011 Individual office or outpatient psychotherapy, approximately 45 to 50 minutes (90806) Yes 200.00 90.34 49.69 0.00 Q,R,S June 24, 2011 Individual office or outpatient psychotherapy, approximately 45 to 50 minutes (90806) Yes 120.00 90.34 49.69 0.00 Q,R,S Total for Claim #46-10326-262-000 $4,120.00 $1,137.64 $776.03 $0.00 T,U,V Jennifer Washington THIS IS NOT A BILL | Page 7 of 8 June 9 – June 24, 2011/Behavioral Medicine Ins continued... Notes for Claims Above Q The approved amount is based on a special payment method. R Outpatient mental health services are paid at 55% of the approved amount. S The previous notice we sent stated the amount you could be charged for this service. This additional payment changed that amount. Your doctor cannot charge you more than $103.89. T 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. U The amount in the Maximum You May Be Billed column has been reduced by the amount you paid the provider at the time the services were rendered. V If you do not agree with the Medicare approved amount(s), you may ask for a reconsideration. You must request a reconsideration within 180 days of the date of receipt of this notice. You may present any new evidence which could affect your decision. Call us at the number in the Customer Service block if you need more information about the reconsideration process. Exhibit 2.12 – Combined Claims, Part B Assigned and Unassigned Jennifer Washington THIS IS NOT A BILL | Page 8 of 8 How to Handle Denied Claims or File an Appeal Get More Details If a claim was denied, call or write the provider and ask for an itemized statement for any claim. Make sure they sent in the right information. If they didn’t, ask the provider to contact our claims office to correct the error. You can ask the provider 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 provider: Ask your provider 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 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 provider 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 2.12 – Combined Claims, Part B Assigned and Unassigned