2.12_Combined_PartB_120907.pdf

of the approved amount.SThe previous notice we sent stated the amount you could be charged for this service. This additional payment changed that amount. Your doctor cannot charge you more than $103.89.TYour claim was sent to your Medicare Supplement Insurance (Medigap policy), Wellmark BlueCross BlueShield of N. Carolina. Send any questions regarding your benefits to them. UThe amount in the Maximum You May Be Billed column has been reduced by the amount you paid the provider at the time the services were rendered.VIf you do not agree with the Medicare approved amount(s), you may ask for a reconsideration. You must request a reconsideration within 180 days of the date of receipt of this notice. You may present any new evidence which could affect your decision. Call us at the number in the Customer Service block if you need more information about the reconsideration process.Exhibit 2.12  Combined Claims, Part B Assigned and UnassignedJennifer Washington THIS IS NOT A BILL | Page 8 of 8How 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 2.12  Combined Claims, Part B Assigned and Unassigned