1.7_PartB_Unassigned_120907.pdf

Page 1 of 5Saba 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)THIS IS NOT A BILLJENNIFER WASHINGTON  TEMPORARY ADDRESS NAMESTREET ADDRESSCITY, ST 12345-6789Medicare Summary Noticefor Part B (Medical Insurance)The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid ServicesYour Deductible StatusYour deductible is what you must pay for most health services before Medicare begins to pay. Part B Deductible:  You have now met $85.00  of your $162.00  deductible for 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.Your Claims & Costs This PeriodDid Medicare Approve All Services? NONumber of Services Medicare Denied 1See claims starting on page 3. Look for NO in the Service Approved? column. See the last page for how to handle a denied claim. Total You May Be Billed $80.88Providers with Claims This PeriodJune 18, 2011  Steven Thiele D CJune 28,  2011  Leo Zygelman, CH June 29, 2011  Joshua Richards, M.D.Notice for Jennifer WashingtonMedicare Number XXX-XX-1234ADate of This Notice September 16, 2011Claims Processed  BetweenJune 15   September 15, 2011Exhibit 1.7  Part B, UnassignedTHIS 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 doctor or provider?  Check the dates. Did you have an appointment that day? Did you get the services 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 doctors 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.  Medicare Preventive ServicesMedicare covers many free or low-cost exams and screenings to help you stay healthy. For more information about preventive services: Talk to your doctor.  Look at your Medicare & You handbook for a complete list. Visit www.MyMedicare.gov for a personalized list.Exhibit 1.7  Part B, UnassignedJennifer Washington THIS IS NOT A BILL | Page 3 of 5Service Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountMedicare  Paid YouMaximum  You May  Be BilledSee  Notes  BelowChiropractic manipulative treatment, 3 to 4 spinal regions (98941-GA)Yes $65.00 $35.55 $0.00 $40.88 A,BTotal for Claim #02-11040-017-700 $65.00 $35.55 $0.00 $40.88 CJune 18, 2011  Steven Thiele D C, (555) 555-1234  Orange Chripractic, 370 Boston Post Rd, Orange, CT 06477-3534Medicare claims may be assigned or unassigned. Your claims below are unassigned meaning the provider hasnt agreed to accept the Medicare-approved amount as payment in full. Do Unassigned Claims Cost More?  Maybe. A provider who doesnt accept assignment may charge you up to 15% over the Medicare-approved amount. This is known as the limiting charge . You may have to pay this amount, or it may be covered by another insurer.For a list of providers that always accept Medicare assignment , visit www.medicare.gov/physician or call 1-800-MEDICARE (1-800-633-4227). You may save money by choosing providers who accept assignment.Definitions of ColumnsService Approved? : This column tells you if Medicare covered the 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. Since your provider hasnt agreed to accept assignment, you might be charged up to 15% more than this amount. Medicare usually pays 80% of the Medicare-approved amount.Medicare Paid You : When a provider doesnt accept assignment, Medicare pays you directly. Youll usually get 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. Continued   Notes for Claims AboveAThis approved amount has been applied toward your deductible.BYour doctor did not accept assignment for this service. Under Federal law, your doctor cannot charge more than $40.88. If you have already paid more than this amount, you are entitled to a refund from the provider.CYour claim was sent to your Medicare Supplement Insurance (Medigap policy), Wellmark BlueCross BlueShield of N. Carolina. Send any questions regarding your benefits to them. Your Unassigned Claims for Part B (Medical Insurance)Exhibit 1.7  Part B, UnassignedService Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountMedicare  Paid YouMaximum  You May  Be BilledSee  Notes  BelowEstablished patient office or other outpatient visit (98213-GA)Yes $64.00 $64.00 $0.00 $0.00 F,GTotal for Claim #02-11040-517-100 $64.00 $64.00 $0.00 $0.00 EService Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountMedicare  Paid YouMaximum  You May  Be BilledSee  Notes  BelowChiropractic manipulative treatment, 3 to 4 spinal regions (98941-GA)NO $40.00 $0.00 $0.00 $40.00 DTotal for Claim #02-11040-307-640 $40.00 $0.00 $0.00 $40.00 EJennifer Washington THIS IS NOT A BILL | Page 4 of 5June 28, 2011Leo Zygelman, CH, (555) 555-123  200 West Center St, Manchester CT 06040-0000June 29, 2011Joshua Richards, M.D., (555) 555-1234  848 Scioto St, Urbana, OH 43078-2255Notes for Claims AboveDThis service was denied. The information provided does not support the need for this service or item.EYour claim was sent to your Medicare Supplement Insurance (Medigap policy), Wellmark BlueCross BlueShield of N. Carolina. Send any questions regarding your benefits to them. FThis approved amount has been applied toward your deductible.GThe 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.Exhibit 1.7  Part B, UnassignedJennifer Washington THIS IS NOT A BILL | Page 5 of 5How 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 1.7  Part B, Unassigned