2.9_ContinuedClaims_120409.pdf

Service Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowEmergency department visit (99285)Yes $434.00 $156.91 $125.53 $31.38Interpretation and report of electrical activity of heart using 1-3 leads (93042)Yes 39.00 7.32 5.86 1.4612-Lead ECG performed (3120F) Yes 0.00 0.00 0.00 0.00 ATotal for Claim #11-10203-914-840 $473.00 $164.23 $131.39 $32.84Jennifer Washington THIS IS NOT A BILL | Page 3 of 5Part 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)July 13, 2011Teresa Lim, M.D., (555) 555-1234 Abington Emergency Phys, PO Box 3012, Wilmington, DE 19804-0012Continued   Notes for Claims AboveAThis code is for informational/reporting purposes only. You should not be charged for this code. If there is a charge, you do not have to pay the amount.Exhibit 2.9  Continued Claims with Continuation BoxService Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowEmergency department visit (99285)Yes $434.00 $184.60 $147.68 $36.92Total for Claim #11-10211-819-140 $434.00 $184.60 $147.68 $36.92Service Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowEmergency department visit (99285)Yes $434.00 $184.60 $147.68 $36.92Total for Claim #11-10217-667-100 $434.00 $184.60 $147.68 $36.92Service Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowEmergency department visit (99285)Yes $434.00 $184.60 $147.68 $36.9212-Lead ECG performed (3120F) Yes 0.00 0.00 0.00 0.00 BTotal for Claim #11-10211-818-070 $434.00 $184.60 $147.68 $36.92Jennifer Washington THIS IS NOT A BILL | Page 4 of 5July 23, 2011Dr. Thomas F. Harkins, M.D., (555) 555-1234 Abington Emergency Phys, PO Box 3012, Wilmington, DE 19804-0012July 25, 2011Dr. Bruce D. Rubin, M.D., (555) 555-1234 Abington Emergency Phys, PO Box 3012, Wilmington, DE 19804-0012July 27, 2011Dr. Philippe A. Kerillis, DO, (555) 555-1234 Abington Emergency Phys, PO Box 3012, Wilmington, DE 19804-0012Continued   Notes for Claims AboveBThis code is for informational/reporting purposes only. You should not be charged for this ode. If there is a charge, you do not have to pay the amount.Exhibit 2.9  Continued Claims with Continuation BoxService Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowPhysician nursing facility visit (99309)Yes $122.00 $89.15 $71.32 $17.83Total for Claim #11-10219-819-150 $122.00 $89.15 $71.32 $17.83Service Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowPhysician nursing facility visit (99308)Yes $93.00 $57.70 $31.74 $25.96 DTotal for Claim #11-10219-828-850 $93.00 $57.70 $31.74 $25.96Service Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowEmergency department visit (99285)Yes $434.00 $184.60 $147.68 $36.9212-Lead ECG performed (3120F) Yes 0.00 0.00 0.00 0.00 CTotal for Claim #11-10218-818-072 $434.00 $184.60 $147.68 $36.92Jennifer Washington THIS IS NOT A BILL | Page 5 of 5August 17, 2011Dr. Steven F. Fisher, M.D., (555) 555-1234 Abington Emergency Phys, PO Box 3012, Wilmington, DE 19804-0012August 22, 2011Cynthia G. Pyle, NP, (555) 555-1234 Abington Memorial Hospital, PO Box 786311, Philadelphia, PA 19178-6311  Referred by Dr. Jennifer O. Orr, M.D.August 19, 2010Dr. Larry S. Keller, DO, (555) 555-1234 Abington Memorial Hospital, PO Box 786311, Philadelphia, PA 19178-6311Notes for Claims AboveCThis code is for informational/reporting purposes only. You should not be charged for this ode. If there is a charge, you do not have to pay the amount.DOutpatient mental health services are paid at 55% of the approved amount.Exhibit 2.9  Continued Claims with Continuation Box