2.12_Combined_PartB_120907.pdf

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 2.12  Combined Claims, Part B Assigned and UnassignedJennifer Washington THIS IS NOT A BILL | Page 3 of 8Part B Medical Insurance helps pay for doctors services, diagnostic tests, ambulance services, and other health care services. Definitions of ColumnsService Approved? : This column tells you if Medicare covered this 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 your 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, 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)Service Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowTherapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minut (97110)Yes $45.00 $28.54 $22.83 $5.71Total for Claim #02-10195-592-677 $45.00 $28.54 $22.83 $5.71 AJune 18, 2011Dr. Susan Jones, M.D., (555) 555-1234 Brevard County Physical Therapy Center, 32 Main Street, Brevard, NC 28712-4187Continued   Notes for Claims AboveAYour 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 2.12  Combined Claims, Part B Assigned and UnassignedService Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowEye and medical examination for diagnosis and treatment, established patient, 1 or more visits (92014)Yes $143.00 $107.97 $86.38 $21.59Computerized mapping of corneal curvature (92025)Yes 0.00 0.00 0.00 0.00 BTotal for Claim #02-10195-592-990 $143.00 $107.97 $86.38 $21.59 CJennifer Washington THIS IS NOT A BILL | Page 4 of 8June 20, 2011Dr. Susan Jones, M.D., (555) 555-1234 Brevard County Physical Therapy Center, 32 Main Street, Brevard, NC 28712-4187Notes for Claims AboveBThis line is for reporting purposes only. You should not be charged. If there is a fee listed, you do not have to pay.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. Continued   Exhibit 2.12  Combined Claims, Part B Assigned and UnassignedService Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountMedicare  Paid YouMaximum  You May  Be BilledSee  Notes  BelowJune 9, 2011Psychiatric interview for diagnosis (90801-59)Yes $500.00 $150.33 $120.26 $0.00 D,EPsychological testing (90830) NO 250.00 0.00 0.00 0.00 FClaim #46-10326-262-000 (continued)Jennifer Washington THIS IS NOT A BILL | Page 5 of 8June 9  June 24, 2011Behavioral Medicine Ins, (555) 555-1234  1401 Pchtree NE St #140, Atlanta, GA 30309-3000Medicare 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/provider 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 AboveDThe approved amount is based on a special payment method.EThe previous notice we sent stated the amount you could be charged for this service. This additional payment changed that amount. Your doctor cannot charge you more than $172.88.FThis item or service was denied  because information required to make payment was incorrect.Your Unassigned Claims for Part B (Medical Insurance)Exhibit 2.12  Combined Claims, Part B Assigned and UnassignedService Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountMedicare  Paid YouMaximum  You May  Be BilledSee  Notes  BelowPsychiatric evaluation of hospital records, reports, testing, or data for diagnosis (90885)Yes 250.00 0.00 0.00 0.00 G,H,I,  JFamily psychotherapy not including patient (90846)Yes 425.00 84.62 46.54 0.00 K,L,MPsychiatric interview for diagnosis (90801-59)Yes 500.00 150.33 120.26 0.00 K,NPsychiatric interview for diagnosis (90801-59)Yes 500.00 150.33 120.26 0.00 K,NPsychiatric interview for diagnosis (90801-59)Yes 500.00 150.33 120.26 0.00 K,NPsychological testing (96100) NO 250.00 0.00 0.00 0.00 OIndividual office or outpatient psychotherapy, approximately 45 to 50 minutes (90806)Yes 250.00 90.34 49.69 0.00 K,L,PIndividual office or outpatient psychotherapy, approximately 45 to 50 minutes (90806)Yes 175.00 90.34 49.69 0.00 K,L,PClaim #46-10326-262-000 (continued)Jennifer Washington THIS IS NOT A BILL | Page 6 of 8June 9  June 24, 2011/Behavioral Medicine Ins continued...Continued   Notes for Claims AboveGPayment is included in another service received on the same day.HMedicare does not pay separately for this service.IYou do not have to pay this amount.JThe previous notice we sent stated the amount you could be charged for this service. This additional payment changed that amount. Your doctor cannot charge you more than $0.00.KThe approved amount is based on a special payment method.LOutpatient mental health services are paid at 55% of the approved amount.MThe previous notice we sent stated the amount you could be charged for this service. This additional payment changed that amount. Your doctor cannot charge you more than $97.31.NThe previous notice we sent stated the amount you could be charged for this service. This additional payment changed that amount. Your doctor cannot charge you more than $172.88.OThis item or service was denied  because information required to make payment was incorrect.PThe previous notice we sent stated the amount you could be charged for this service. This additional payment changed that amount. Your doctor cannot charge you more than $103.89.Exhibit 2.12  Combined Claims, Part B Assigned and UnassignedService Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountMedicare  Paid YouMaximum  You May  Be BilledSee  Notes  BelowIndividual office or outpatient psychotherapy, approximately 45 to 50 minutes (90806)Yes 200.00 90.34 49.69 0.00 Q,R,SJune 16, 2011Individual office or outpatient psychotherapy, approximately 45 to 50 minutes (90806)Yes 200.00 90.34 49.69 0.00 Q,R,SJune 24, 2011Individual office or outpatient psychotherapy, approximately 45 to 50 minutes (90806)Yes 120.00 90.34 49.69 0.00 Q,R,STotal for Claim #46-10326-262-000 $4,120.00 $1,137.64 $776.03 $0.00 T,U,VJennifer Washington THIS IS NOT A BILL | Page 7 of 8June 9  June 24, 2011/Behavioral Medicine Ins continued...Notes for Claims AboveQThe approved amount is based on a special payment method.ROutpatient mental health services are paid at 55% of the approved amount.SThe previous notice we sent stated the amount you could be charged for this service. This additional payment changed that amount. Your doctor cannot charge you more than $103.89.TYour claim was sent to your Medicare Supplement Insurance (Medigap policy), Wellmark BlueCross BlueShield of N. Carolina. Send any questions regarding your benefits to them. UThe 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.VIf you do not agree with the Medicare approved amount(s), you may ask for a reconsideration. You must request a reconsideration within 180 days of the date of receipt of this notice. You may present any new evidence which could affect your decision. Call us at the number in the Customer Service block if you need more information about the reconsideration process.Exhibit 2.12  Combined Claims, Part B Assigned and UnassignedJennifer Washington THIS IS NOT A BILL | Page 8 of 8How 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