Medicare Summary Notices - English Exhibits - 2.8_AdjustedClaim_120925.pdf

Service Provided & Billing Code Service Approved? Amount Provider Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Ultrasonic guidance for placement of needle (76942-26) Yes – adjusted $95.00 $95.00 $76.00 $19.00 Ultrasonic guidance for placement of needle (76942-26) Yes – adjusted 95.00 35.81 28.65 7.16 Ultrasonic guidance for placement of needle (76942-26) Yes – adjusted 95.00 35.81 28.65 7.16 Total for Claim #02-10195-592-700 $285.00 $166.62 $133.30 $33.32 A,B Jennifer Washington THIS IS NOT A BILL | Page 3 of 5 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) October 13, 2010 Samuel G. Putnam M.D., (555) 555-1234 Univ of Penn – Comm Rad, 999 Old Eagle School Road, Suite 118, Wayne, PA 19087-1707 Referred by David G Nazarian 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. B This is an adjustment to a previously processed claim and/or deductible record. Exhibit 2.8 – Adjusted Claim