evekhm/cms_iom_500 huggingface dataset:
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0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 291.06 291.06 291.06 0.00 U,WClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveUThis service is paid at 100% of the Medicare approved amount.WLocal Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of LCD # L27375. Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 18 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowMagnesium level (83735) Yes 291.06 291.06 291.06 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 291.06 291.06 291.06 0.00
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0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 291.06 291.06 291.06 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveXThis service is paid at 100% of the Medicare approved amount.YLocal Coverage
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72.77 72.77 0.00 XClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveXThis service is paid at 100% of the Medicare approved amount.YLocal Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of LCD # L27375. Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 19 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowPhosphate level (84100) Yes 72.77 72.77 0.00 0.00 ZPhosphate level (84100) Yes 218.31 218.31 0.00 0.00 ZPhosphate level (84100) Yes 218.31 218.31 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 218.31 218.31 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54
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Yes 218.31 218.31 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZUrine potassium level (84133) Yes 34.18 34.18 0.00 0.00 ZUrine potassium level (84133) Yes 34.18 34.18 0.00 0.00 ZUrine sodium level (84300) Yes 31.97 31.97 0.00 0.00 ZUrine sodium level (84300) Yes 31.97 31.97 0.00 0.00 ZUrine sodium level (84300) Yes 31.97 31.97 0.00 0.00 ZBlood test, thyroid stimulating hormone (TSH) (84443)Yes 153.80 153.80 0.00 0.00 ZTroponin (protein) analysis (84484) Yes 183.02 183.02 0.00 0.00 ZTroponin (protein) analysis (84484) Yes 183.02 183.02 0.00 0.00 ZTroponin (protein) analysis (84484) Yes 83.02 83.02 0.00 0.00 ZTroponin (protein) analysis (84484) Yes 83.02 83.02 0.00 0.00 ZTroponin (protein) analysis (84484) Yes 83.02 83.02 0.00 0.00 ZUrea nitrogen level to assess kidney function (84540)Yes 169.79 169.79 0.00 0.00 ZSyphilis detection test (86592) Yes 73.87 73.87 0.00 0.00 ZDetection test for Influenza virus, A or B (87400)Yes 140.76 140.76 0.00 0.00 ZClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveZThis service is paid at 100% of the Medicare approved amount.Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 20 of 26Ocboter 20  November
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paid at 100% of the Medicare approved amount.Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 20 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowComplete blood cell count (red cells, white blood cell, platelets), automated test (85025)Yes 48.51 48.51 0.00 0.00 aComplete blood cell count (red cells, white blood cell, platelets), automated test (85025)Yes 97.02 97.02 0.00 0.00 aComplete blood cell count (red cells, white blood cell, platelets), automated test (85025)Yes 97.02 97.02 0.00 0.00 aComplete blood cell count (red cells, white blood cell, platelets), automated test (85025)Yes 97.02 97.02 0.00 0.00 aComplete blood cell count (red cells, white blood cell, platelets), automated test (85025)Yes 97.02 97.02 0.00 0.00 aComplete blood cell count (red cells, white blood cell, platelets), automated test (85025)Yes 97.02 97.02 0.00 0.00 aComplete blood cell count (red cells, white blood cell, platelets), automated test (85025)Yes 97.02 97.02 0.00 0.00 aComplete blood cell count (red cells, white blood cell, platelets), automated test (85025)Yes 97.02 97.02 0.00 0.00 aComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 37.11 37.11 0.00 0.00 bComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 37.11 37.11 0.00 0.00 aComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 37.11 37.11 0.00 0.00 aClaim
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37.11 37.11 0.00 0.00 aComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 37.11 37.11 0.00 0.00 aClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveaThis service is paid at 100% of the Medicare approved amount.bThis item or service cannot be paid as billed.Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 21 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 37.11 37.11 0.00 0.00 cComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 37.11 37.11 0.00 0.00 cComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 37.11 37.11 0.00 0.00 cComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 37.11 37.11 0.00 0.00 cComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 74.22 74.22 0.00 0.00 cComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 74.22 74.22 0.00 0.00 cComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 111.33 111.33 0.00 0.00 cComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 74.22 74.22 0.00 0.00 cComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 74.22 74.22 0.00
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(85027)Yes 74.22 74.22 0.00 0.00 cComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 74.22 74.22 0.00 0.00 cComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 111.33 111.33 0.00 0.00 cComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 111.33 111.33 0.00 0.00 cClaim #21035000422104NYA (continued)Continued   Notes for Claims AbovecThis service is paid at 100% of the Medicare approved amount.Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 22 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowCoagulation function measurement (85379)Yes 136.71 136.71 0.00 0.00 dCoagulation function measurement (85379)Yes 136.71 136.71 0.00 0.00 dCoagulation function measurement (85379)Yes 136.71 136.71 0.00 0.00 dFibrinogen (Factor 1) antigen detection (85385)Yes 44.10 44.10 0.00 0.00 dFibrinogen (Factor 1) antigen detection (85385)Yes 44.10 44.10 0.00 0.00 dFibrinogen (Factor 1) antigen detection (85385)Yes 44.10 44.10 0.00 0.00 dFibrinogen (Factor 1) antigen detection (85385)Yes 44.10 44.10 0.00 0.00 dFibrinogen (Factor 1) antigen detection (85385)Yes 88.20 88.20 0.00 0.00 dFibrinogen (Factor 1) antigen detection (85385)Yes 88.20 88.20 0.00 0.00 dBlood test, clotting time
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88.20 88.20 0.00 0.00 dFibrinogen (Factor 1) antigen detection (85385)Yes 88.20 88.20 0.00 0.00 dBlood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 dBlood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 dBlood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 dBlood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 dBlood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 dBlood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 dBlood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 dBlood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 dBlood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 dBlood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 dBlood test, clotting time (85610) Yes 74.98 74.98 0.00 0.00 dBlood test, clotting time (85610) Yes 74.98 74.98 0.00 0.00 dBlood test, clotting time (85610) Yes 74.98 74.98 0.00 0.00 dBlood test, clotting time (85610) Yes 74.98 74.98 0.00 0.00 dBlood test, clotting time (85610) Yes 74.98 74.98 0.00 0.00 dBlood test, clotting time (85610) Yes 74.98 74.98 0.00 0.00 dClaim #21035000422104NYA (continued)Continued   Notes for Claims AbovedThis service is paid at 100% of the Medicare approved amount.Exhibit 2.11  Combined Claims, Part
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0.00 0.00 dClaim #21035000422104NYA (continued)Continued   Notes for Claims AbovedThis service is paid at 100% of the Medicare approved amount.Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 23 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowBacterial blood culture (87040) Yes 131.13 131.13 131.13 0.00 eBacterial blood culture (87040) Yes 232.26 232.26 232.26 0.00 fBacterial blood culture (87040) Yes 232.26 232.26 232.26 0.00 fBacterial blood culture (87040) Yes 232.26 232.26 232.26 0.00 fStool culture (87045) Yes 91.51 91.51 91.51 0.00 fBacterial culture (87070) Yes 108.05 108.05 108.05 0.00 fBacterial culture (87070) Yes 108.05 108.05 108.05 0.00 fBacterial culture (87070) Yes 108.05 108.05 108.05 0.00 fBacterial culture and colony count for anaerobic bacteria (87073)Yes 121.25 121.25 121.25 0.00 fBacterial urine culture (87088) Yes 34.18 34.18 34.18 0.00 fBacterial urine culture (87088) Yes 34.18 34.18 34.18 0.00 fBacterial urine culture (87088) Yes 68.36 68.36 68.36 0.00 fFungal blood culture (mold or yeast) (87103)Yes 113.93 113.93 113.93 0.00 fSmear for parasites (87177) Yes 104.74 104.74 104.74 0.00 fImmunologic analysis for detection of organism (87449)Yes 156.56 156.56 156.56 0.00 fImmunologic analysis for detection of organism (87449)Yes 156.56 156.56 156.56 0.00 fDetection test for organism
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156.56 156.56 156.56 0.00 fImmunologic analysis for detection of organism (87449)Yes 156.56 156.56 156.56 0.00 fDetection test for organism (87798) Yes 511.56 511.56 511.56 0.00 fDetection test for organism (87798) Yes 1,534.68 1,534.68 1,534.68 0.00 fSpecial stained specimen slides to identify organisms (88312)Yes 166.48 166.48 166.48 6.10Cell examination of specimen (88112)Yes 155.45 155.45 155.45 12.79Special stain for parasites (87209) Yes 69.46 69.46 69.46 0.00 fPathology examination of tissue using a microscope, moderately high complexity (88307)Yes 339.57 339.57 339.57 18.47Special stained specimen slides to identify organisms (88312)Yes 998.88 998.88 998.88 36.60Claim #21035000422104NYA (continued)Continued   Notes for Claims AboveeThis service is paid at 100% of the Medicare approved amount.fThis item or service cannot be paid as billed.Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 24 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowTissue or cell analysis by immunologic technique (88342)Yes 255.78 255.78 255.78 0.00 g,hXray of abdomen, single view (74000)Yes 213.06 213.06 213.06 10.55Xray of abdomen, single view (74000)Yes 213.06 213.06 213.06 10.55Xray of abdomen, single view (74000)Yes 213.06 213.06 213.06 10.55Xray of chest, 1 view, front (71010) Yes 667.01 667.01 667.01 21.09Xray of chest, 1 view, front
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213.06 213.06 213.06 10.55Xray of chest, 1 view, front (71010) Yes 667.01 667.01 667.01 21.09Xray of chest, 1 view, front (71010) Yes 1,124.55 1,124.55 1,124.55 31.64Xray 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 10.55Xray 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
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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
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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
2.12_Combined_PartB_120907.pdf
Page 1 of 8Medicare 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 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.THIS IS NOT A BILLJENNIFER WASHINGTON  TEMPORARY ADDRESS NAMESTREET ADDRESSCITY, ST 12345-6789Your Claims & Costs This PeriodDid Medicare Approve All Services? NONumber of Services Medicare Denied 2See 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 $27.30Providers with Claims This PeriodJune 18  20, 2011  Susan Jones, M.D.June 9  June 24, 2011  Behavioral Medicine Ins Saba 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 2.12  Combined Claims, Part B Assigned and UnassignedTHIS IS NOT A BILL | Page 2 of 8 Jennifer WashingtonMaking the Most of Your Medicare
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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.