1.1_PartA_Inpatient_120907.pdf

Medicare Summary Noticefor Part A (Hospital Insurance) The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid ServicesYour Deductible StatusYour deductible is what you must pay each benefit period for most health services before Medicare begins to pay. Part A Deductible:  You have now met your $1,068.00 deductible for inpatient hospital services for the benefit period that began May 27, 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, 2011Saba 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)Your Claims & Costs This PeriodDid Medicare Approve All Claims? YESSee page 2 for how to double-check this notice.Total You May Be Billed $2,062.50Facilities with Claims This PeriodJune 18  June 29, 2011  Otero HospitalJuly 1  July 18, 2011  Lexington Health CenterPage 1 of 5Exhibit 1.1  Part A, InpatientTHIS IS NOT A BILL | Page 2 of 5 Jennifer WashingtonMaking the Most of Your Medicare  How to Check This NoticeDo you recognize the name of each facility?  Check the dates.Did you get the claims 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 facility 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 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 Benefit PeriodsYour hospital and skilled nursing facility (SNF) stays are measured in benefit days  and benefit periods . Every day that you spend in a hospital or SNF counts toward the benefit days in that benefit period. A benefit period begins the day you first receive inpatient hospital services or, in certain circumstances, SNF services, and ends when you havent received any inpatient care in a hospital or inpatient skilled care in a SNF for 60 days in a row. Inpatient Hospital: You have 56 out of 90 covered benefit days  remaining for the benefit period that began May 27, 2011.Skilled Nursing Facility: You have 63 out of 100 covered benefit days  remaining for the benefit period that began May 27, 2011.See your Medicare & You handbook for more information on benefit periods.  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 1.1  Part A, InpatientJennifer Washington THIS IS NOT A BILL | Page 3 of 5Benefit  Days  UsedClaim  Approved?Non-  Covered  ChargesAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowBenefit Period starting May 27, 2011 1 day Yes $0.00 $6,583.00 $0.00Total for Claim #20906900033902 $0.00 $6,583.00 $0.00 APart A Inpatient Hospital Insurance helps pay for inpatient hospital care, inpatient care in a skilled nursing facility following a hospital stay, home health care, and hospice care. Definitions of ColumnsBenefit Days Used: The number of covered benefit days you used during each hospital and/or skilled nursing facility stay. (See page 2 for more information and a summary of your benefit periods.)  Claim Approved?: This column tells you if Medicare covered the inpatient stay.  Non-Covered Charges: This is the amount Medicare didnt pay. Amount Medicare Paid: This is the amount Medicare paid your inpatient facility.Maximum You May Be Billed: The amount you may be billed for Part A services can include a deductible, coinsurance based on your benefit days used, and other charges. For more information about Medicare Part A coverage, see your Medicare & You handbook.Your Inpatient Claims for Part A (Hospital Insurance)June 18  June 21, 2011Otero Hospital, (555) 555-1234  PO Box 1142, Manati, PR 00674Referred by Jesus Sarmiento ForastiJune 29, 2011Otero Hospital, (555) 555-1234  PO Box 1142, Manati, PR 00674Referred by Carlos Santiago DiazBenefit  Days  UsedClaim  Approved?Non-  Covered  ChargesAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowBenefit Period starting May 27, 2011 4 days Yes $0.00 $4,886.98 $0.00Total for Claim #20905400034102 $0.00 $4,886.98 $0.00 AContinued   Notes for Claims AboveADays are being subtracted from your total inpatient hospital benefits for this benefit period. The Your Benefit Periods section on page 2 has more details.Exhibit 1.1  Part A, InpatientJennifer Washington THIS IS NOT A BILL | Page 4 of 5Benefit  Days  UsedClaim  Approved?Non-  Covered  ChargesAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowBenefit Period starting May 27, 2011 17 days Yes $0.00 $7,012.27 $2,062.50Total for Claim #21034400232702ILA $0.00 $7,012.27 $2,062.50 B,CJuly 1  July 18, 2011Lexington Health Center, (555) 555-1234  815e Irving Park Rd, Streamwood, IL 60107-3073Referred by Warren PierceNotes for Claims AboveBDays are being subtracted from your total skilled nursing facility benefits for this benefit period. The Your Benefit Periods section on page 2 has more details.C$2,062.50 was applied to your skilled nursing facility coinsurance.Exhibit 1.1  Part A, InpatientFile 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, 2011Jennifer Washington THIS IS NOT A BILL | Page 5 of 5How to Handle Denied Claims or File an Appeal Exhibit 1.1  Part A, InpatientPage 1 of 5Medicare Summary Noticefor Part A (Hospital Insurance) The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid ServicesYour Deductible StatusYour deductible is what you must pay each benefit period for most health services before Medicare begins to pay. Part A Deductible:  You have now met your $1,068.00  deductible for inpatient hospital services for the benefit period that began May 27, 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 12345-6789Saba 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)Your Claims & Costs This PeriodDid Medicare Approve All Claims? NONumber of Services Medicare Denied 2See claims starting on page 3. Look for NO in the Claim Approved? column. See the last page for how to handle a denied claim. Total You May Be Billed $2,062.50Facilities with Claims This PeriodJune 18  June 29, 2011  Otero HospitalJuly 1  July 18, 2011  Lexington Health CenterNotice for Jennifer WashingtonMedicare Number XXX-XX-1234ADate of This Notice September 16, 2011Claims Processed  BetweenJune 15   September 15, 2011Exhibit 1.1  Part A, Inpatient page 1 with denied claims