1.3_PartA_Hospice_120921.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 did not have inpatient hospital claims this claim period, so you did not have to pay towards the Part A deductible.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 Services? YESSee page 2 for how to double-check this notice.Total You May Be Billed $0.00Providers with Claims This PeriodJune 23  June 30, 2011  Allina Health SystemPage 1 of 4Exhibit 1.3  Part A, HospiceTHIS IS NOT A BILL | Page 2 of 4 Jennifer WashingtonMaking the Most of Your Medicare  How to Check This NoticeDo you recognize the name of each doctor or provider?  Check the dates. Did you have a visit or service that day?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 provider 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 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 1.3  Part A, HospiceJennifer Washington THIS IS NOT A BILL | Page 3 of 4Your Hospice Claims for Part A (Hospital Insurance)Notes for Claims AboveAYou should not be billed for this service. You are only responsible for any deductible and coinsurance amounts listed in the Maximum You May Be Billed column.Part A 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 ColumnsService Approved?: This column tells you if Medicare covered the hospice 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 asfull payment for covered services. Medicare usually pays 80% of the Medicare-approved amount.Amount Medicare Paid : This is the amount Medicare paid the 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. This is usually $0, but can include copayments for outpatient prescription drugs, as well as 5% of the Medicare-approved amount for inpatient respite care. If you have Medicare Supplement Insurance (Medigap policy) or other insurance, it may pay all or part of this amount.Quantity & Service ProvidedService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  Below4 Routine Home Care, weeks Yes $2,000.00 $0.00 $0.00 $0.00 A12 Skilled Nursing Visits12 Medical Social Visits40 Continuous Home Health Care, hoursYes 3,000.00 0.00 0.00 0.00 A5 Skilled Nursing VisitsTotal for Claim #21122800455102MNR $5,000.00 $0.00 $0.00 $0.00June 23  June 30, 2011Alina Health System, (555) 555-1234  1055 Westgate Drive, Suite 100, St. Paul, MN 55114-1451Referred by Deb BurgymdExhibit 1.3  Part A, HospiceFile 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 12345-6789Get 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, 2011Jennifer Washington THIS IS NOT A BILL | Page 4 of 4How to Handle Denied Claims or File an Appeal Exhibit 1.3  Part A, Hospice