Medicare Summary Notices - English Exhibits - 2.7_NoneRemain_120409.pdf

Benefit Days Used Claim Approved? Non- Covered Charges Amount Medicare Paid Maximum You May Be Billed See Notes Below Benefit Period starting Oct. 2, 2011 none remain NO $480,579.03 $0.00 $480,579.30 Total for Claim #21036201645104ILA $480,579.03 $0.00 $480,579.30 A Jennifer Washington THIS IS NOT A BILL | Page 3 of 5 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) November 9 – December 21, 2011 Swedish Covenant Hospital, (555) 555-1234 5145n California Ave, Chicago, IL 60640-4213 Referred by Ermias Tilahun Continued Notes for Claims Above A You have used all of your benefit days for this period. Exhibit 2.7 – Part A None-Remian Benefit Days