1.8_DME_Assigned_120907.pdf

Page 1 of 6Medicare Summary Noticefor Part B (Medical Insurance)The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid ServicesTHIS IS NOT A BILLJENNIFER WASHINGTON  TEMPORARY ADDRESS NAMESTREET ADDRESSCITY, ST 12345-6789Your 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 Items and Services?YESSee page 2 for how to double-check your notice.Total You May Be Billed $61.31Suppliers with Claims This PeriodMay 9, 2011  Lincare Inc.June 12, 2011  Prof Healing SolutionsJuly 6  August 8, 2011  Walgreens CoSaba 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)Notice for Jennifer WashingtonMedicare Number XXX-XX-1234ADate of This Notice September 16, 2011Claims Processed  BetweenJune 15   September 15, 2011Exhibit 1.8  DME, AssignedTHIS IS NOT A BILL | Page 2 of 6 Jennifer WashingtonMaking the Most of Your Medicare   How to Check This NoticeDo you recognize the name of each supplier?  Check the dates. Did you make a purchase  that day?Did you get the items/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 supplier 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 medical supplies. 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 1.8  DME, AssignedQuantity, Item/Service Provided  & Billing CodeItem/  Service  Approved?Amount  Supplier  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  Below1 oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concen (E1390-RR) RentalYes $442.00 $173.17 $138.54 $34.63 ATotal for Claim #10334829487000 $442.00 $173.17 $138.54 $34.63 BJennifer Washington THIS IS NOT A BILL | Page 3 of 6Part B Medical Insurance helps pay for durable medical equipment and other health care services. Definitions of ColumnsItem/Service Approved? : This column tells you if Medicare covered this item or service. Amount Supplier Charged : This is your suppliers fee for this item or service. Medicare-Approved Amount : This is the amount a supplier can be paid for a Medicare item or service. It may be less than the actual amount the supplier charged. Your supplier has agreed to accept thisamount as full payment for covered items or services. Medicare usually pays 80% of the Medicare-approved amount.Amount Medicare Paid : This is the amount Medicare paid the supplier. This is usually 80% of the Medicare-approved amount. Maximum You May Be Billed : This is the total amount the supplier 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)May 9, 2011Lincare Inc., (555) 555-1234  PO BOX 996, Blue Springs, MO 64013-0996  Ordered by John K WhalenContinued   Notes for Claims AboveAMedicare will pay for you to rent this equipment for up to 36 months (or until you no longer need the equipment). After the 36 month rental period, Medicare will continue to pay for delivery of liquid and gaseous contents, as long as it is still medically necessary.BYour claim was sent to your Medicare Supplement Insurance (Medigap policy), Wellmark BlueCross BlueShield of N. Carolina. Send any questions regarding your benefits to them. Exhibit 1.8  DME, AssignedQuantity, Item/Service Provided  & Billing CodeItem/  Service  Approved?Amount  Supplier  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  Below1 portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifie (E0431-RR) RentalYes $117.61 $28.77 $23.02 $5.75 C Total for Claim #10334829489000 $117.61 $28.77 $23.02 $5.75 DQuantity, Item/Service Provided  & Billing CodeItem/  Service  Approved?Amount  Supplier  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  Below63 conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to three inches (A6446-A1) Yes $31.00 $27.09 $21.67 $5.42Total for Claim #10323807216000 $31.00 $27.09 $21.67 $5.42 DJennifer Washington THIS IS NOT A BILL | Page 4 of 6May 9, 2011Lincare Inc., (555) 555-1234  PO BOX 996, Blue Springs, MO 64013-0996  Ordered by John K WhalenJune 12, 2011Prof Healing Solutions, (555) 555-1234  2497 S Roane St, Ste 220, Harriman, TN 37748-8689  Ordered by Barry DickNotes for Claims AboveCMedicare will pay for you to rent this equipment for up to 36 months (or until you no longer need the equipment). After the 36 month rental period, Medicare will continue to pay for delivery of liquid and gaseous contents, as long as it is still medically necessary.DYour claim was sent to your Medicare Supplement Insurance (Medigap policy), Wellmark BlueCross BlueShield of N. Carolina. Send any questions regarding your benefits to them. Exhibit 1.8  DME, AssignedQuantity, Item/Service Provided  & Billing CodeItem/  Service  Approved?Amount  Supplier  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  Below2 blood glucose test or reagent strips for home blood glucose monitor, per 50 strips (A4253-NUKX) Specific Required DocumentationYes $124.99 $77.56 $62.05 $15.51Total for Claim #10320806344000 $124.99 $77.56 $62.05 $15.51 EJennifer Washington THIS IS NOT A BILL | Page 5 of 6July 6  August 8, 2011Walgreen Co, (555) 555-1234  PO BOX 90482, Chicago, IL 60696-0482  Ordered by Patrick T BurnsNotes for Claims AboveEYour claim was sent to your Medicare Supplement Insurance (Medigap policy), Wellmark BlueCross BlueShield of N. Carolina. Send any questions regarding your benefits to them. Exhibit 1.8  DME, AssignedJennifer Washington THIS IS NOT A BILL | Page 6 of 6How to Handle Denied Claims or File an Appeal Get More DetailsIf a claim was denied, call or write the supplier and ask for an itemized statement for any claim.  Make sure they sent in the right information. If they didnt, ask the supplier to contact our claims office to correct the error. You can ask the supplier for an itemized statement for any item 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 supplier:  Ask your supplier 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, 2012File an Appeal in WritingFollow these steps:1Circle the item(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 supplier 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 1.8  DME, Assigned