2.11_Combined_A_121015.pdf

of chest, 1 view, front (71010) Yes 374.85 374.85 374.85 10.55Xray of chest, 1 view, front (71010) Yes 374.85 374.85 374.85 10.55Xray of chest, 1 view, front (71010) Yes 374.85 374.85 374.85 10.55Xray of chest, 1 view, front (71010) Yes 374.85 374.85 374.85 10.55Xray of chest, 1 view, front (71010) Yes 374.85 374.85 374.85 10.55Total for Claim #21035000422104NYA $63,960.35 $63,960.35 $63,960.35 $234.64Notes for Claims AbovegMedicare cannot pay for this service for the diagnosis shown on the claim.hYou 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.Continued   Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 25 of 26Your Home Health Claims for Part A (Hospital Insurance)Notes for Claims AboveiWhat Medicare pays for a service or item may be higher than the billed amount. The Medicare payment amount is correct. Medicare pays this provider less than the billed amount on other claims since payment rates are set in advance for certain services and averaged out over an entire year.Quantity & Service ProvidedService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  Below6 Physical Therpy Yes $1,200.00 $2,093.37 $2,093.37 $0.001 Occupation Therapy Yes 200.00 200.00 200.00 0.004 Skilled Nursing Yes 720.00 920.00 920.00 0.00Total for Claim #20022000001804NYR $2,120.00 $3,213.37 $3,213.37 $0.00 iPart 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 home health 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 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. For durable medical equipment, it can include 20% of the Medicare-approved amount. If you have Medicare Supplement Insurance (Medigap policy) or other insurance, it may pay all or part of this amount.September 10  October 20, 2011Heartland Home Health Care, (555) 555-1234  4855 W Hillsboro Blvd, Suite B-4, Coconut Creek, FL 33073-4356Referred by Marta LacayoExhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthFile 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 facility 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 hospital or facility and ask for an itemized statement for any claim. Make sure they sent in the right information. If they didnt, ask the facility to contact our claims office to correct the error. You can ask the facility 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 facility:  Ask your facility 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 26 of 26How to Handle Denied Claims or File an Appeal Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home Health