2.11_Combined_A_121015.pdf

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 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 3 of 26Part 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)July 29  September 3, 2011The New York and Presbyterian Hospital, (555) 555-1234  525 East 68th Street, New York NY 10065-4870Referred by Jesse WiltBenefit  Days  UsedClaim  Approved?Non-  Covered  ChargesAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowBenefit Period starting June 18, 2009 13 days Yes $112,431.00 $13,477.52 $119,373.00 ATotal for Claim #20905400034102 $112,431.00 $13,477.52 $119,373.00 B,CContinued   Notes for Claims AboveAServices after 08/10/09 cannot be paid because your benefits were exhausted.B13 of the Benefit Days were charged to your Lifetime Reserve Day benefit.CThis 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 4 of 26Part B Medical Insurance helps pay for outpatient care provided by certified medical facilities, such as hospital outpatient departments, renal dialysis facilities, and community health centers. Definitions of ColumnsService Approved?: This column tells you if Medicare covered the outpatient service.Amount Facility Charged: This is your facilitys fee for this service.Medicare-Approved Amount : This is the amount a facility can be paid for a Medicare service. It may be less than the actual amount the facility charged. Thefacility 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 the facility. This is usually 80% of the Medicare-approved amount. Maximum You May Be Billed : This is the total amount the facility 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 Outpatient Claims for Part B (Medical Insurance)October 20  November 23, 2011The New York and Presbyterian Hospital, (555) 555-1234  525 East 68th Street, New York NY 10065-4870Referred by Selim M. ArcasoyService Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowLiver function blood test panel (80076)Yes $69.46 $69.46 $69.46 $0.00 DLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 DLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 DLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 DLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 DLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 DLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 DClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveDThis 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 5 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  BelowLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 EDrug screen (80101) Yes 81.68 81.68 81.68 0.00 E,FVancomycin (antibiotic) level (80202)Yes 134.51 134.51 134.51 0.00 EVancomycin (antibiotic) level (80202)Yes 134.51 134.51 134.51 0.00 EVancomycin (antibiotic) level (80202)Yes 134.51 134.51 134.51 0.00 EManual urinalysis test with examination using microscope (81001)Yes 47.41 47.41 47.41 0.00 EClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveEThis service is paid at 100% of the Medicare approved amount.FLocal 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 6 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  BelowManual urinalysis test with examination using microscope (81001)Yes 47.41 47.41 47.41 0.00 GManual urinalysis test with examination using microscope (81001)Yes 47.41 47.41 47.41 0.00 GManual urinalysis test with examination using microscope (81001)Yes 94.82 94.82 94.82 0.00 GAutomated urinalysis test (81003) Yes 36.38 36.38 36.38 0.00 GUrine chloride level (82436) Yes 44.10 44.10 44.10 0.00 GUrine chloride level (82436) Yes 44.10 44.10 44.10 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 363.84 363.84 363.84 0.00 GBlood gases measurement (82805) Yes 242.56 242.56 242.56 0.00 GChemical analysis using spectrophotometry (light) (84311)Yes 347.29 347.29 347.29 0.00 GChemical analysis using spectrophotometry (light) (84311)Yes 347.29 347.29 347.29 0.00 GThyroxine (thyroid chemical) measurement (84439)Yes 151.04 151.04 151.04 0.00 GThyroid hormone, T3 measurement (84481)Yes 256.88 256.88 256.88 0.00 GClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveGThis 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 7 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Continued   Notes for Claims AboveHThis 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  BelowRed blood cell concentration measurement (85014)Yes 19.85 19.85 19.85 0.00 HRed blood cell concentration measurement (85014)Yes 59.55 59.55 59.55 0.00 HRed blood cell concentration measurement