2.10_Breaking_LongNotes_120409.pdf

Service Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowXray of thigh, 2 views professional charge (73550-26LT) Yes $38.00 $8.83 $7.06 $1.77CT scan head or brain professional charge (70450-62GZ) Yes 179.00 0.00 0.00 0.00 A,BTotal for Claim #11-10336-697-750 $217.00 $8.83 $7.06 $1.77 CJennifer Washington THIS IS NOT A BILL | Page 3 of 7Part 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)November 15, 2010Dr. Martin Simmerman, P.M. M.D., (555) 555-1234 Arnette Clinic, LLC, 8016 Reliable Pkwy, Chicago, IL 60686-0001  Referredy by Alaimo, Andrew AContinued   Notes for Claims AboveALocal 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 #L28516.BIt appears that you did not know that we would not pay for this service, so you are not liable. Do not pay your provider for this service. If you have paid your provider for this service, you should submit to this office three things: 1) a copy of this notice, 2) your providers bill, and 3) a receipt or proof that you have paid the bill. You must file your written request for payment within 6 months of the date of this notice. Future services of this type provided to you will be your responsibility.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. Exhibit 2.10  Breaking Claims with Long NotesService Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowUltrasound examination of heart including color-depicted blood flow rate, direction, and valve function professional charge (93306-26)Yes $211.00 $69.84 $55.87 $13.97Total for Claim #11-10340-695-690 $211.00 $69.84 $55.87 $13.97 DService Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowXray of knee, 3 views professional charge (73562-26LT)Yes $40.00 $9.56 $7.65 $1.91CT scan abdomen professional charge (74150-26)Yes 238.00 60.20 48.16 12.04CT scan pelvis professional charge (72192-26)Yes 211.00 55.23 44.18 11.05Xray of shoulder, minimum of 2 views professional charge  (73030-26LT)Yes 42.00 9.56 7.65 1.91Total for Claim #11-10217-667-100 $531.00 $134.55 $107.64 $26.91 DJennifer Washington THIS IS NOT A BILL | Page 4 of 7November 17, 2011Dr. Priit Jaagosild, M.D., (555) 555-1234 Arnette Clinic, LLC, 8016 Reliable Pkwy, Chicago, IL 60686-0001  Referredy by Dupre, Gary WNovember 17, 2011Dr. Martin Simmerman, P.M. M.D., (555) 555-1234 Arnette Clinic, LLC, 8016 Reliable Pkwy, Chicago, IL 60686-0001  Referredy by Alaimo, Andrew AContinued   Notes for Claims AboveDYour 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 2.10  Breaking Claims with Long NotesService Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowNovember 18, 2011Physical therapy evaluation  (97001-GP)Yes $100.00 $78.83 $15.00 $0.00 EApplication of hot or cold packs to 1 or more areas (97010-GP)Yes 10.00 0.00 0.00 0.00 F,G,HTherapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes  (97112-GP)Yes 60.00 33.31 0.00 0.00 ITherapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes (97110-GP)Yes 50.00 32.00 0.00 0.00 JNovember 20, 2011Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes  (97112-GP)Yes 60.00 33.31 0.00 0.00Claim #83-11011-003-050 (continued)Jennifer Washington THIS IS NOT A BILL | Page 5 of 7November 18  November 20, 2011Dr. Priit Jaagosild, M.D., (555) 555-1234 Arnette Clinic, LLC, 8016 Reliable Pkwy, Chicago, IL 60686-0001  Referredy by Dupre, Gary WContinued   Notes for Claims AboveEYour provider agreed to accept $68.00 as payment in full on this claim. Your primary insurer has already paid $53.00 so Medicares payment is the difference between the two amounts.FPayment is included in another service received on the same day.GYou do not have to pay this amount.HIf you have already paid it, you are entitled to a refund from this provider.IYour primary insurer approved and paid $60.00 on this claim. Therefore, no secondary payment will be made by Medicare.JYour primary insurer approved and paid $50.00 on this claim. Therefore, no secondary payment will be made by Medicare.Exhibit 2.10  Breaking Claims with Long NotesService Provided & Billing CodeItem  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 minutes (97110-GP)Yes 50.00 32.00 0.00 0.00 K,L,MTotal for Claim #83-11011-003-050 $290.00 $177.45 $30.00 $0.00 N,O,PJennifer Washington THIS IS NOT A BILL | Page 6 of 7November 18  November 20, 2011/Dr. Priit Jaagosild, M.D. continued...Notes for Claims AboveKPayment is included in another service received on the same day.LYou do not have to pay this amount.MIf you have already paid it, you are entitled to a refund from this provider.NYour claim was sent to your Medicare Supplement Insurance (Medigap policy), Wellmark BlueCross BlueShield of N. Carolina. Send any questions regarding your benefits to them. OOf the $30.00 paid on this claim, we are paying you $15.00 because you paid your provider more than your 20 percent coinsurance on Medicare approved services. The remaining $15.00 was paid to the provider.P$1735.94 has been applied during this calendar year 2010 towards the $1,860.00 limit on outpatient physical therapy and speech-language pathology benefits.Exhibit 2.10  Breaking Claims with Long Notes