1.2_BofA_120907.pdf

How to Get Help with Your Questions1-800-MEDICARE (1-800-633-4227)  Ask for hospital 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.Exhibit 1.2  B of AService Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowLiver function blood test panel (80076)Yes $69.46 $69.46 $69.46 $0.00 ALiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ALiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ALiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ALiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ALiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ALiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 AClaim #21035000422104NYA (continued)Jennifer Washington THIS IS NOT A BILL | Page 3 of 6Part B Medical Insurance helps pay for outpatient care provided by certified medical facilities, such as hospital outpatient departments, renal dialysis facilities, and community health centers. Definitions of ColumnsService Approved?: This column tells you if Medicare covered the outpatient service.Amount Facility Charged: This is your facilitys fee for this service.Medicare-Approved Amount : This is the amount a facility can be paid for a Medicare service. It may be less than the actual amount the facility charged. Thefacility 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 the facility. This is usually 80% of the Medicare-approved amount. Maximum You May Be Billed : This is the total amount the facility 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 Outpatient Claims for Part B (Medical Insurance)July 19  August 22, 2011The New York and Presbyterian Hospital, (555) 555-1234  525 East 68th Street, New York NY 10065-4870Referred by Selim M. ArcasoyContinued   Notes for Claims AboveAThis service is paid at 100% of the Medicare-approved amount.Exhibit 1.2  B of AService Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 BLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 BLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 BLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 BLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 BLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 BLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 BLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 BLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 BLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 BLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 BDrug screen (80101) Yes 81.68 81.68 81.68 0.00 B,CVancomycin (antibiotic) level (80202)Yes 134.51 134.51 134.51 0.00 BVancomycin (antibiotic) level (80202)Yes 134.51 134.51 134.51 0.00 BVancomycin (antibiotic) level (80202)Yes 134.51 134.51 134.51 0.00 BManual urinalysis test with examination using microscope (81001)Yes 47.41 47.41 47.41 0.00 BClaim #21035000422104NYA (continued)Jennifer Washington THIS IS NOT A BILL | Page 4 of 5July 19  August 22, 2011/The New York and Presbyterian Hospital continued...Notes for Claims AboveBThis service is paid at 100% of the Medicare-approved amount.CLocal 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 #L27375. Continued   Exhibit 1.2  B of AService Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowManual urinalysis test with examination using microscope (81001)Yes 47.41 47.41 47.41 0.00 DManual urinalysis test with examination using microscope (81001)Yes 47.41 47.41 47.41 0.00 DManual urinalysis test with examination using microscope (81001)Yes 94.82 94.82 94.82 0.00 DAutomated urinalysis test (81003) Yes 36.38 36.38 36.38 0.00 DUrine chloride level (82436) Yes 44.10 44.10 44.10 0.00 DUrine chloride level (82436) Yes 44.10 44.10 44.10 0.00 DBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 DBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 DBlood gases measurement (82805) Yes 485.12 485.12 485.12 0.00 DBlood gases measurement (82805) Yes 606.40 606.40 606.40 0.00 DBlood gases measurement (82805) Yes 606.40 606.40 606.40 0.00 DBlood gases measurement (82805) Yes 485.12 485.12 485.12 0.00 DBlood gases measurement (82805) Yes 485.12 485.12 485.12 0.00 DBlood gases measurement (82805) Yes 363.84 363.84 363.84 0.00 DBlood gases measurement (82805) Yes 363.84 363.84 363.84 0.00 DBlood gases measurement (82805) Yes 242.84 242.84 242.84 0.00 DBlood gases measurement (82805) Yes 242.56 242.56 242.56 0.00 DBlood gases measurement (82805) Yes 363.84 363.84 363.84 0.00 DBlood gases measurement (82805) Yes 242.56 242.56 242.56 0.00 DChemical analysis using spectrophotometry (light) (84311)Yes 347.29 347.29 347.29 0.00 DChemical analysis using spectrophotometry (light) (84311)Yes 347.29 347.29 347.29 0.00 DThyroxine (thyroid chemical) measurement (84439)Yes 151.04 151.04 151.04 0.00 DTotal for Claim #21035000422104NYA $7,672.94 $7,672.94 $7,915.50 $0.00Jennifer Washington THIS IS NOT A BILL | Page 5 of 6July 19  August 22, 2011/The New York and Presbyterian Hospital continued...Notes for Claims AboveDThis service is paid at 100% of the Medicare-approved amount.Exhibit 1.2  B of AJennifer Washington THIS IS NOT A BILL | Page 6 of 6How to Handle Denied Claims or File an Appeal File 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 facility 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 12345-6789Get More DetailsIf a claim was denied, call or write the hospital or facility and ask for an itemized statement for any claim. Make sure they sent in the right information. If they didnt, ask the facility to contact our claims office to correct the error. You can ask the facility 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 facility:  Ask your facility 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, 2011Exhibit 1.2  B of A