Medicare Summary Notices - English Exhibits - 2.1_Duplicate_120907.pdf

Page 1 of 5 Medicare Summary Notice for Part B (Medical Insurance) The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid Services DUPLICATE COPY 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) 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 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 $150.86 Providers with Claims This Period June 18, 2011 Susan Jones, M.D. June 28, 2011 Craig I. Secosan, M.D. June 29 – June 30, 2011 Edward J. Mcginley M.D. 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 2.1 – Duplicate MSN Header