2.11_Combined_A_121015.pdf

test performed by hand-held instrument (92962)Yes 252.00 252.00 252.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 308.00 308.00 308.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 308.00 308.00 308.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 308.00 308.00 308.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 308.00 308.00 308.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 252.00 252.00 252.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 308.00 308.00 308.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 364.00 364.00 364.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 84.00 84.00 84.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 84.00 84.00 84.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 140.00 140.00 140.00 0.00 RClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveRThis service is paid at 100% of the Medicare approved amount.Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 15 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 112.00 112.00 112.00 0.00 SBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 84.00 84.00 84.00 0.00 SBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 112.00 112.00 112.00 0.00 SBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 56.00 56.00 56.00 0.00 SBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 112.00 112.00 112.00 0.00 SBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 112.00 112.00 112.00 0.00SBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 112.00 112.00 112.00 0.00 SBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 336.00 336.00 336.00 0.00 SBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 336.00 336.00 336.00 0.00 SBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 308.00 308.00 308.00 0.00 SBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 196.00 196.00 196.00 0.00 SClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveSThis service is paid at 100% of the Medicare approved amount.Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 16 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Continued   Notes for Claims AboveTThis service is paid at 100% of the Medicare approved amount.Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 308.00 308.00 308.00 0.00 TBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 280.00 280.00 280.00 0.00 TBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 280.00 280.00 280.00 0.00 TBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 336.00 336.00 336.00 0.00 TBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 364.00 364.00 364.00 0.00 TBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 308.00 308.00 308.00 0.00 TBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 140.00 140.00 140.00 0.00 TGlutamyltransferase (liver enzyme) level (82977)Yes 88.20 88.20 88.20 0.00 TGlutamyltransferase (liver enzyme) level (82977)Yes 88.20 88.20 88.20 0.00 TGlutamyltransferase (liver enzyme) level (82977)Yes 88.20 88.20 88.20 0.00 TGlutamyltransferase (liver enzyme) level (82977)Yes 88.20 88.20 88.20 0.00 TGlutamyltransferase (liver enzyme) level (82977)Yes 88.20 88.20 88.20 0.00 THaptoglobin (serum protein) level (83010)Yes 76.07 76.07 76.07 0.00 TLactic acid level (83605) Yes 184.12 184.12 184.12 0.00 TLactic acid level (83605) Yes 184.12 184.12 184.12 0.00 TClaim #21035000422104NYA (continued)Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 17 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowLactic acid level (83605) Yes 184.12 184.12 184.12 0.00 ULactic acid level (83605) Yes 184.12 184.12 184.12 0.00 ULactic acid level (83605) Yes 184.12 184.12 184.12 0.00 ULactic acid level (83605) Yes 184.12 184.12 184.12 0.00 ULactic acid level (83605) Yes 184.12 184.12 184.12 0.00 ULactic acid level (83605) Yes 184.12 184.12 184.12 0.00 ULactic acid level (83605) Yes 184.12 184.12 184.12 0.00 ULactic acid level (83605) Yes 184.12 184.12 184.12 0.00 ULactic acid level (83605) Yes 184.12 184.12 184.12 0.00 ULactic acid level (83605) Yes 184.12 184.12 184.12 0.00 ULactate dehydrogenase (enzyme) level (83615)Yes 69.46 69.46 69.46 0.00 ULipase (fat enzyme) level (83690) Yes 38.59 38.59 38.59 0.00 UMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 291.06 291.06 291.06 0.00 U,WClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveUThis service is paid at 100% of the Medicare approved amount.WLocal 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. Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 18 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowMagnesium level (83735) Yes 291.06 291.06 291.06 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes