Medicare Summary Notices - English Exhibits - 2.5_ProviderHeader_120622.pdf

Benefit Days Used Item Approved? Non- Covered Charges Amount Medicare Paid Maximum You May Be Billed See Notes Below Benefit Period starting June 18, 2011 4 days Yes $0.00 $4,886.98 $0.00 Total for Claim #20905400034102 $0.00 $4,886.98 $0.00 A June 18 – June 20, 2011 Otero Hospital, (555) 555-1234 PO Box 1142, Manati, PR 00674 Referred by Dr. Jesus Sarmiento Forasti Exhibit 2.5a – Provider Header Format: Part A 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 Service Provided & Billing Code Item Approved? Amount Provider Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below June 29, 2010 Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report (93010) NO $55.00 $0.00 $0.00 $55.00 D,E,F June 30, 2010 Destruction of skin growth (17000) NO 68.56 0.00 0.00 68.56 D Total for Claim #02-10204-674-840 $123.56 $0.00 $0.00 $123.56 June 18, 2011 Aisa G. Lopez, (555) 555-1234 8046 Crittenden St, Philadelphia, PA 19118-0000 Referred by Roy K Augusthy June 29 – June 30, 2011 Edward J. Mcginley, M.D., (555) 555-1234 Nazareth Cardiology PC, 3037 Smith Ave, Philadelphia, PA 19182-0001 Referred by Hanh-Nhon Doan Exhibit 2.5b – Provider Header Format: Part B 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 A Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 A Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 A Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 A Liver function blood test panel (80076) Yes 69.46 69.46 69.46 0.00 A Liver function blood test panel (80076) Yes 69.46 69.46 69.46 $0.00 A Liver function blood test panel (80076) Yes 69.46 69.46 69.46 $0.00 A Total for Claim #21035000422104NYA $486.22 $486.22 $486.22 $0.00 July 19 – August 22, 2011 The New York and Presbyterian Hospital, (555) 555-1234 525 East 68th Street, New York NY 10065-4870 Referred by Selim M. Arcasoy Exhibit 2.5c – Provider Header Format: ‘B of A’ 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 (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 May 9, 2011 Lincare Inc., (555) 555-1234 PO BOX 996, Blue Springs, MO 64013-0996 Ordered by John K Whalen Exhibit 2.5d – Provider Header Format: DME