1.6_PartB_Assigned_120907.pdf

How to Check This NoticeDo you recognize the name of each doctor or provider?  Check the dates. Did you have an appointment that day? Did you get the services listed?  Do they match those listed on your receipts and bills?If you already paid the bill, did you pay the right amount?  Check the maximum you may be billed. See if the claim was sent to your Medicare supplement insurance (Medigap) plan or other insurer. That plan may pay your share.   How to Report FraudIf you think a provider or business is involved in fraud, call us at 1-800-MEDICARE  (1-800-633-4227). Some examples of fraud include offers for free medical services, or billing you for Medicare services you didnt get. If we determine that your tip led to uncovering fraud, you may qualify for a reward.You can make a difference!  Last year, Medicare saved tax-payers $4 billion the largest sum ever recovered in a single yearthanks to people who reported suspicious activity to Medicare.  How to Get Help with Your Questions1-800-MEDICARE (1-800-633-4227)  Ask for doctors services. Your customer-service code is 05535.TTY 1-877-486-2048 (for hearing impaired)Contact your State Health Insurance Program (SHIP) for free, local health insurance counseling. Call 1-555-555-5555 .  Your Messages from MedicareGet a pneumococcal shot.  You may only need it once in a lifetime. Contact your health care provider about getting this shot. You pay nothing if your health care provider accepts Medicare assignment.To report a change of address , call Social Security at 1-800-772-1213. TTY users should call  1-800-325-0778.Early detection is your best protection.  Schedule your mammogram today, and remember that Medicare helps pay for screening mammograms. Do you use therapy services? Watch the limit! In 2011, Medicares annual coverage limit for most outpatient physical therapy and speech language pathology is $1,860 combined.  Medicare Preventive ServicesMedicare covers many free or low-cost exams and screenings to help you stay healthy. For more information about preventive services: Talk to your doctor.  Look at your Medicare & You handbook for a complete list. Visit www.MyMedicare.gov for a personalized list.Exhibit 1.6  Part B, AssignedService Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowTherapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minut (97110)Yes $45.00 $28.54 $22.83 $5.71Total for Claim #02-10195-592-677 $45.00 $28.54 $22.83 $5.71 AJennifer Washington THIS IS NOT A BILL | Page 3 of 5Part B Medical Insurance helps pay for doctors services, diagnostic tests, ambulance services, and other health care services. Definitions of ColumnsService Approved? : This column tells you if Medicare covered this service. Amount Provider Charged : This is your providers 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)June 18, 2011Dr. Susan Jones, M.D., (555) 555-1234 Brevard County Physical Therapy Center, 32 Main Street, Brevard, NC 28712-4187Continued   Notes for Claims AboveAYour claim was sent to your Medicare Supplement Insurance (Medigap policy), Wellmark BlueCross BlueShield of N. Carolina. Send any questions regarding your benefits to them. Exhibit 1.6  Part B, AssignedService Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowJune 29, 2011Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report (93010)NO $55.00 $0.00 $0.00 $55.00 D,EJune 30, 2011Destruction of skin growth (17000) NO 68.56 0.00 0.00 68.56 DTotal for Claim #02-10204-674-840 $123.56 $0.00 $0.00 $123.56 CService Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowEye and medical examination for diagnosis and treatment, established patient, 1 or more visits (92014)Yes $143.00 $107.97 $86.38 $21.59Computerized mapping of corneal curvature (92025)Yes 0.00 0.00 0.00 0.00 BTotal for Claim #02-10195-592-390 $143.00 $107.97 $86.38 $21.59 CJennifer Washington THIS IS NOT A BILL | Page 4 of 5June 28, 2011Craig I. Secosan, M.D., (555) 555-1234  Looking Glass Eye Center PA, 1888 Medical Park Dr, Suite C, Brevard, NC 28712-4187June 29  June 30, 2011Edward J. Mcginley, M.D., (555) 555-1234  Nazareth Cardiology PC, 3037 Smith Ave, Philadelphia, PA 19182-0001  Referred by Hanh-Nhon DoanNotes for Claims AboveBThis line is for reporting purposes only. You should not be charged. If there is a fee listed, you do not have to pay.CYour claim was sent to your Medicare Supplement Insurance (Medigap policy), Wellmark BlueCross BlueShield of N. Carolina. Send any questions regarding your benefits to them. DThis service was denied.  The information provided does not support the need for this service or item.ELocal Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of LCD #L27490. Exhibit 1.6  Part B, AssignedJennifer Washington THIS IS NOT A BILL | Page 5 of 5How to Handle Denied Claims or File an Appeal Get More DetailsIf a claim was denied, call or write the provider and ask for an itemized statement for any claim.  Make sure they sent in the right information. If they didnt, ask the provider to contact our claims office to correct the error. You can ask the provider for an itemized statement for any service or claim.Call 1-800- MEDICARE  (1-800-633-4227) for more information about a coverage or payment decision on this notice, including laws or policies used to make the decision.If You Need Help Filing Your AppealContact us:  Call 1-800-M EDICARE or your State Health Insurance Program (see page 2) for help before you file your written appeal, including help appointing a representative. Call your provider:  Ask your provider for any information that may help you. Ask a friend to help:  You can appoint someone, such as a family member or friend, to be your representative in the appeals process.Find Out More About AppealsFor more information about appeals, read your Medicare & You handbook or visit us online at www.medicare.gov/appeals.If You Disagree with a Coverage Decision, Payment Decision, or Payment Amount on this Notice, You Can Appeal Appeals must be filed in writing.  Use the form to the right. Our claims office must receive your appeal within 120 days from the date you get this notice. We must receive your appeal by:  January 14, 2011File an Appeal in WritingFollow these steps:1Circle the service(s) or claim(s) you disagree with on this notice.2Explain in writing why you disagree with  the decision. Include your explanation on this notice or, if you need more space, attach a separate page to this notice.3Fill in all of the following:Your or your representatives full name (print)Your or your representatives signatureYour telephone numberYour complete Medicare number4Include any other information you have about your appeal. You can ask your provider for any information that will help you.5Write your Medicare number on all documents that you send.6Make copies of this notice and all supporting documents for your records.7Mail this notice and all supporting documents to the following address:Medicare Claims Office  c/o Contractor Name  Street Address  City, ST 12345-6789Exhibit 1.6  Part B, AssignedPage 1 of 5Your Deductible StatusYour 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.THIS IS NOT A BILLJENNIFER WASHINGTON  TEMPORARY ADDRESS NAMESTREET ADDRESSCITY, ST 12345-6789Notice for Jennifer WashingtonMedicare Number XXX-XX-1234ADate of This Notice September 16, 2011Claims Processed  BetweenJune 15   September 15, 2011Your Claims & Costs This PeriodDid Medicare Approve All Claims? YESSee page 2 for how to double-check your notice.Total You May Be Billed $150.86Providers with Claims This PeriodJune 18, 2011  Susan Jones, M.D.June 28, 2011  Craig I. Secosan, M.D. June 29  June 30, 2011  Edward J. Mcginley M.D. Saba que puede recibir este aviso y otro tipo de ayuda de Medicare en espaol? Llame y hable con un agente en espaol.     agent ,  Mandarin .                   1-800-MEDICARE (1-800-633-4227)Medicare Summary Noticefor Part B (Medical Insurance)The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid ServicesExhibit 1.6  Part B, Assigned page 1 with all approved claims