evekhm/cms_iom_500 huggingface dataset:
1.9_DME_Unassigned_120907.pdf
$138.54 $199.15 A,B,CMay 9, 2011Lincare Inc., (555) 555-1234  PO BOX 996, Blue Springs, MO 64013-0996  Ordered by John K WhalenExhibit 1.9  DME, 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 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
1.9_DME_Unassigned_120907.pdf
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 1.9  DME, Unassigned
2.10_Breaking_LongNotes_120409.pdf
Service Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowXray of thigh, 2 views professional charge (73550-26LT) Yes $38.00 $8.83 $7.06 $1.77CT scan head or brain professional charge (70450-62GZ) Yes 179.00 0.00 0.00 0.00 A,BTotal for Claim #11-10336-697-750 $217.00 $8.83 $7.06 $1.77 CJennifer Washington THIS IS NOT A BILL | Page 3 of 7Part 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)November 15, 2010Dr. Martin Simmerman, P.M. M.D., (555) 555-1234 Arnette Clinic, LLC, 8016 Reliable Pkwy, Chicago, IL 60686-0001  Referredy by Alaimo, Andrew AContinued   Notes for Claims AboveALocal 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 #L28516.BIt appears that you did not know that
2.10_Breaking_LongNotes_120409.pdf
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 #L28516.BIt appears that you did not know that we would not pay for this service, so you are not liable. Do not pay your provider for this service. If you have paid your provider for this service, you should submit to this office three things: 1) a copy of this notice, 2) your providers bill, and 3) a receipt or proof that you have paid the bill. You must file your written request for payment within 6 months of the date of this notice. Future services of this type provided to you will be your responsibility.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. Exhibit 2.10  Breaking Claims with Long NotesService Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowUltrasound examination of heart including color-depicted blood flow rate, direction, and valve function professional charge (93306-26)Yes $211.00 $69.84 $55.87 $13.97Total for Claim #11-10340-695-690 $211.00 $69.84 $55.87 $13.97 DService Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowXray of knee, 3 views professional charge (73562-26LT)Yes $40.00 $9.56 $7.65 $1.91CT scan abdomen professional charge (74150-26)Yes 238.00 60.20 48.16 12.04CT scan pelvis professional charge (72192-26)Yes 211.00 55.23 44.18 11.05Xray of shoulder, minimum of 2 views professional charge  (73030-26LT)Yes 42.00 9.56 7.65 1.91Total for Claim #11-10217-667-100 $531.00 $134.55 $107.64 $26.91 DJennifer Washington THIS IS NOT A BILL | Page 4 of
2.10_Breaking_LongNotes_120409.pdf
7.65 1.91Total for Claim #11-10217-667-100 $531.00 $134.55 $107.64 $26.91 DJennifer Washington THIS IS NOT A BILL | Page 4 of 7November 17, 2011Dr. Priit Jaagosild, M.D., (555) 555-1234 Arnette Clinic, LLC, 8016 Reliable Pkwy, Chicago, IL 60686-0001  Referredy by Dupre, Gary WNovember 17, 2011Dr. Martin Simmerman, P.M. M.D., (555) 555-1234 Arnette Clinic, LLC, 8016 Reliable Pkwy, Chicago, IL 60686-0001  Referredy by Alaimo, Andrew AContinued   Notes for Claims AboveDYour 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 2.10  Breaking Claims with Long NotesService Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowNovember 18, 2011Physical therapy evaluation  (97001-GP)Yes $100.00 $78.83 $15.00 $0.00 EApplication of hot or cold packs to 1 or more areas (97010-GP)Yes 10.00 0.00 0.00 0.00 F,G,HTherapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes  (97112-GP)Yes 60.00 33.31 0.00 0.00 ITherapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes (97110-GP)Yes 50.00 32.00 0.00 0.00 JNovember 20, 2011Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes  (97112-GP)Yes 60.00 33.31 0.00 0.00Claim #83-11011-003-050 (continued)Jennifer Washington THIS IS NOT A BILL | Page 5 of 7November 18  November 20, 2011Dr. Priit Jaagosild, M.D., (555) 555-1234
2.10_Breaking_LongNotes_120409.pdf
(continued)Jennifer Washington THIS IS NOT A BILL | Page 5 of 7November 18  November 20, 2011Dr. Priit Jaagosild, M.D., (555) 555-1234 Arnette Clinic, LLC, 8016 Reliable Pkwy, Chicago, IL 60686-0001  Referredy by Dupre, Gary WContinued   Notes for Claims AboveEYour provider agreed to accept $68.00 as payment in full on this claim. Your primary insurer has already paid $53.00 so Medicares payment is the difference between the two amounts.FPayment is included in another service received on the same day.GYou do not have to pay this amount.HIf you have already paid it, you are entitled to a refund from this provider.IYour primary insurer approved and paid $60.00 on this claim. Therefore, no secondary payment will be made by Medicare.JYour primary insurer approved and paid $50.00 on this claim. Therefore, no secondary payment will be made by Medicare.Exhibit 2.10  Breaking Claims with Long NotesService Provided & Billing CodeItem  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 minutes (97110-GP)Yes 50.00 32.00 0.00 0.00 K,L,MTotal for Claim #83-11011-003-050 $290.00 $177.45 $30.00 $0.00 N,O,PJennifer Washington THIS IS NOT A BILL | Page 6 of 7November 18  November 20, 2011/Dr. Priit Jaagosild, M.D. continued...Notes for Claims AboveKPayment is included in another service received on the same day.LYou do not have to pay this amount.MIf you have already paid it, you are entitled to a refund from this provider.NYour claim was sent to your Medicare Supplement Insurance (Medigap policy), Wellmark BlueCross BlueShield of N. Carolina. Send any questions regarding your benefits to them. OOf the $30.00 paid on this claim, we are paying you $15.00 because you paid your provider more than your 20 percent coinsurance on
2.10_Breaking_LongNotes_120409.pdf
BlueShield of N. Carolina. Send any questions regarding your benefits to them. OOf the $30.00 paid on this claim, we are paying you $15.00 because you paid your provider more than your 20 percent coinsurance on Medicare approved services. The remaining $15.00 was paid to the provider.P$1735.94 has been applied during this calendar year 2010 towards the $1,860.00 limit on outpatient physical therapy and speech-language pathology benefits.Exhibit 2.10  Breaking Claims with Long Notes
2.11_Combined_A_121015.pdf
Medicare Summary Noticefor Part A (Hospital Insurance) and 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 each benefit period for most health services before Medicare begins to pay. Part A Deductible:  You have now met your $1,068.00  deductible for inpatient hospital  services for the benefit period that began June 18, 2010. Part B Deductible: You have 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 12345-6789Saba 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)Facilities and Providers with Claims  This PeriodJuly 29  September 3, 2011  Otero HospitalSeptember 20  October 10, 2011  Heartland Home Health CareOctober 20  November 23, 2011  The New York and Presbyterian HospitalPage 1 of 26Notice for Jennifer WashingtonMedicare Number XXX-XX-1234ADate of This Notice December 16, 2011Claims Processed  BetweenOctober 15   December 15, 2011Your Claims & Costs This PeriodDid Medicare Approve All Claims and Services?YESSee page 2 for how to double-check this notice.Total You May Be Billed $119,607.64Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthTHIS IS NOT A BILL | Page 2 of 26 Jennifer WashingtonMaking the Most of Your Medicare
2.11_Combined_A_121015.pdf
How to Check This NoticeDo you recognize the name of each facility?  Check the dates.Did you get the claims 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 facility 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 hospital 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 Benefit PeriodsYour hospital and skilled nursing facility (SNF) stays are measured in benefit days  and benefit periods . Every day that you spend in a hospital or SNF counts toward the benefit days in that benefit period. A benefit period begins the day you first receive inpatient hospital services or, in certain circumstances, SNF services, and ends when you havent received any inpatient care in a hospital or inpatient skilled care in a SNF for 60 days in a row. Inpatient Hospital: You have used all of your 90 covered benefit days for the benefit period that began June 18, 2010.Inpatient Lifetime Reserve:  You have used all of your 60 lifetime reserve days.See your Medicare & You handbook for more information on benefit periods.
2.11_Combined_A_121015.pdf
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 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 3 of 26Part A Inpatient 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 ColumnsBenefit Days Used: The number of covered benefit days you used during each hospital and/or skilled nursing facility stay. (See page 2 for more information and a summary of your benefit periods.)  Claim Approved?: This column tells you if Medicare covered the inpatient stay.  Non-Covered Charges: This is the amount Medicare didnt pay. Amount Medicare Paid: This is the amount Medicare paid your inpatient facility.Maximum You May Be Billed: The amount you may be billed for Part A services can include a deductible, coinsurance based on your benefit days used, and other charges. For more information about Medicare Part A coverage, see your Medicare & You handbook.Your Inpatient Claims for Part A (Hospital Insurance)July 29  September 3, 2011The New York and Presbyterian Hospital, (555) 555-1234  525 East 68th Street, New York NY 10065-4870Referred by Jesse WiltBenefit  Days  UsedClaim  Approved?Non-  Covered  ChargesAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowBenefit Period starting June 18, 2009 13 days Yes $112,431.00 $13,477.52 $119,373.00 ATotal for Claim #20905400034102 $112,431.00 $13,477.52 $119,373.00
2.11_Combined_A_121015.pdf
$13,477.52 $119,373.00 ATotal for Claim #20905400034102 $112,431.00 $13,477.52 $119,373.00 B,CContinued   Notes for Claims AboveAServices after 08/10/09 cannot be paid because your benefits were exhausted.B13 of the Benefit Days were charged to your Lifetime Reserve Day benefit.CThis 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 4 of 26Part B Medical Insurance helps pay for outpatient care provided by certified medical facilities, such as hospital outpatient departments, renal dialysis facilities, and community health centers. Definitions of ColumnsService Approved?: This column tells you if Medicare covered the outpatient service.Amount Facility Charged: This is your facilitys fee for this service.Medicare-Approved Amount : This is the amount a facility can be paid for a Medicare service. It may be less than the actual amount the facility charged. Thefacility 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 facility. This is usually 80% of the Medicare-approved amount. Maximum You May Be Billed : This is the total amount the facility 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 Outpatient Claims for Part B (Medical Insurance)October 20  November 23, 2011The New York and Presbyterian Hospital, (555) 555-1234  525 East 68th Street, New York NY 10065-4870Referred by Selim M. ArcasoyService Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowLiver function blood test panel (80076)Yes $69.46 $69.46 $69.46 $0.00 DLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 DLiver function blood test panel
2.11_Combined_A_121015.pdf
$69.46 $69.46 $69.46 $0.00 DLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 DLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 DLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 DLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 DLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 DLiver function blood test panel (80076)Yes 69.46 69.46 69.46 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 5 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  BelowLiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test
2.11_Combined_A_121015.pdf
blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 ELiver function blood test panel (80076)Yes 69.46 69.46 69.46 0.00 EDrug screen (80101) Yes 81.68 81.68 81.68 0.00 E,FVancomycin (antibiotic) level (80202)Yes 134.51 134.51 134.51 0.00 EVancomycin (antibiotic) level (80202)Yes 134.51 134.51 134.51 0.00 EVancomycin (antibiotic) level (80202)Yes 134.51 134.51 134.51 0.00 EManual urinalysis test with examination using microscope (81001)Yes 47.41 47.41 47.41 0.00 EClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveEThis service is paid at 100% of the Medicare approved amount.FLocal 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 6 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  BelowManual urinalysis test with examination using microscope (81001)Yes 47.41 47.41 47.41 0.00 GManual urinalysis test with examination using microscope (81001)Yes 47.41 47.41 47.41 0.00 GManual urinalysis test with examination using microscope (81001)Yes 94.82
2.11_Combined_A_121015.pdf
0.00 GManual urinalysis test with examination using microscope (81001)Yes 47.41 47.41 47.41 0.00 GManual urinalysis test with examination using microscope (81001)Yes 94.82 94.82 94.82 0.00 GAutomated urinalysis test (81003) Yes 36.38 36.38 36.38 0.00 GUrine chloride level (82436) Yes 44.10 44.10 44.10 0.00 GUrine chloride level (82436) Yes 44.10 44.10 44.10 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 121.28 121.28 121.28 0.00 GBlood gases measurement (82805) Yes 363.84 363.84 363.84 0.00 GBlood gases measurement (82805) Yes 242.56 242.56 242.56 0.00 GChemical analysis using spectrophotometry (light) (84311)Yes 347.29 347.29 347.29 0.00 GChemical analysis using spectrophotometry (light) (84311)Yes 347.29 347.29