Medicare Summary Notices - English Exhibits - 2.9_ContinuedClaims_120409.pdf

Service Provided & Billing Code Service Approved? Amount Provider Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Emergency department visit (99285) Yes $434.00 $156.91 $125.53 $31.38 Interpretation and report of electrical activity of heart using 1-3 leads (93042) Yes 39.00 7.32 5.86 1.46 12-Lead ECG performed (3120F) Yes 0.00 0.00 0.00 0.00 A Total for Claim #11-10203-914-840 $473.00 $164.23 $131.39 $32.84 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) July 13, 2011 Teresa Lim, M.D., (555) 555-1234 Abington Emergency Phys, PO Box 3012, Wilmington, DE 19804-0012 Continued Notes for Claims Above A This code is for informational/reporting purposes only. You should not be charged for this code. If there is a charge, you do not have to pay the amount. Exhibit 2.9 – Continued Claims with Continuation Box Service Provided & Billing Code Service Approved? Amount Provider Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Emergency department visit (99285) Yes $434.00 $184.60 $147.68 $36.92 Total for Claim #11-10211-819-140 $434.00 $184.60 $147.68 $36.92 Service Provided & Billing Code Service Approved? Amount Provider Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Emergency department visit (99285) Yes $434.00 $184.60 $147.68 $36.92 Total for Claim #11-10217-667-100 $434.00 $184.60 $147.68 $36.92 Service Provided & Billing Code Service Approved? Amount Provider Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Emergency department visit (99285) Yes $434.00 $184.60 $147.68 $36.92 12-Lead ECG performed (3120F) Yes 0.00 0.00 0.00 0.00 B Total for Claim #11-10211-818-070 $434.00 $184.60 $147.68 $36.92 Jennifer Washington THIS IS NOT A BILL | Page 4 of 5 July 23, 2011 Dr. Thomas F. Harkins, M.D., (555) 555-1234 Abington Emergency Phys, PO Box 3012, Wilmington, DE 19804-0012 July 25, 2011 Dr. Bruce D. Rubin, M.D., (555) 555-1234 Abington Emergency Phys, PO Box 3012, Wilmington, DE 19804-0012 July 27, 2011 Dr. Philippe A. Kerillis, DO, (555) 555-1234 Abington Emergency Phys, PO Box 3012, Wilmington, DE 19804-0012 Continued Notes for Claims Above B This code is for informational/reporting purposes only. You should not be charged for this ode. If there is a charge, you do not have to pay the amount. Exhibit 2.9 – Continued Claims with Continuation Box Service Provided & Billing Code Service Approved? Amount Provider Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Physician nursing facility visit (99309) Yes $122.00 $89.15 $71.32 $17.83 Total for Claim #11-10219-819-150 $122.00 $89.15 $71.32 $17.83 Service Provided & Billing Code Service Approved? Amount Provider Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Physician nursing facility visit (99308) Yes $93.00 $57.70 $31.74 $25.96 D Total for Claim #11-10219-828-850 $93.00 $57.70 $31.74 $25.96 Service Provided & Billing Code Service Approved? Amount Provider Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Emergency department visit (99285) Yes $434.00 $184.60 $147.68 $36.92 12-Lead ECG performed (3120F) Yes 0.00 0.00 0.00 0.00 C Total for Claim #11-10218-818-072 $434.00 $184.60 $147.68 $36.92 Jennifer Washington THIS IS NOT A BILL | Page 5 of 5 August 17, 2011 Dr. Steven F. Fisher, M.D., (555) 555-1234 Abington Emergency Phys, PO Box 3012, Wilmington, DE 19804-0012 August 22, 2011 Cynthia G. Pyle, NP, (555) 555-1234 Abington Memorial Hospital, PO Box 786311, Philadelphia, PA 19178-6311 Referred by Dr. Jennifer O. Orr, M.D. August 19, 2010 Dr. Larry S. Keller, DO, (555) 555-1234 Abington Memorial Hospital, PO Box 786311, Philadelphia, PA 19178-6311 Notes for Claims Above C This code is for informational/reporting purposes only. You should not be charged for this ode. If there is a charge, you do not have to pay the amount. D Outpatient mental health services are paid at 55% of the approved amount. Exhibit 2.9 – Continued Claims with Continuation Box