MSN B sample1.pdf

Medicare Summary Notice

BENEFICIARY NAME

STREET ADDRESS

CITY, STATE ZIP CODE

CUSTOMER SERVICE INFORMATION

Your Medicare Number: 111-11-1111A

If you have questions, write or call:

Medicare (#12345) 555 Medicare Blvd., Suite 200 Medicare Building Medicare, US XXXXX-XXXX

Call: 1-800-MEDICARE (1-800-633-4227) Ask for Doctor Services TTY for Hearing Impaired: 1-877-486-2048

BE INFORMED: Beware of telemarketers offering free or discounted medicare items or services.

This is a summary of claims processed from 05/10/2006 through 08/10/2006.

PART B MEDICAL INSURANCE – ASSIGNED CLAIMS

Dates Medicare You See of Amount Medicare Paid May Be Notes

Service Services Provided Charged Approved Provider Billed Section

Claim Number: 12435-84956-84556 Paul Jones, M.D., 123 West Street, a

Jacksonville, FL 33231-0024 Referred by: Scott Wilson, M.D.

04/19/06 1 Influenza immunization (90724) $5.00 $3.88 $3.88 $0.00 b 04/19/06 1 Admin. flu vac (G0008) 5.00 3.43 3.43 0.00 b

Claim Total $10.00 $7.31 $7.31 $0.00

Claim Number: 12435-84956-84557 ABC Ambulance, P.O. Box 2149, a

Jacksonville, FL 33231 04/25/06 1 Ambulance, base rate (A0020) $289.00 $249.78 $199.82 $49.96 04/25/06 1 Ambulance, per mile (A0021) 21.00 16.96 13.57 3.39

Claim Total $310.00 $266.74 $213.39 $53.35

PART B MEDICAL INSURANCE – UNASSIGNED CLAIMS

Dates Medicare You See of Amount Medicare Paid May Be Notes

Service Services Provided Charged Approved You Billed Section

Claim Number: 12435-84956-84558 William Newman, M.D., 362 North Street a

Jacksonville, FL 33231-0024 03/10/06 1 Office/Outpatient Visit, ES (99213) $47.00 $33.93 $27.15 $39.02 c

THIS IS NOT A BILL – Keep this notice for your records.

July 1, 2006

Your Medicare Number: 111-11-1111A

Notes Section:

a This information is being sent to your private insurer. They will review it to see if additional benefits can be paid. Send any questions regarding your supplemental benefits to them.

b This service is paid at 100% of the Medicare approved amount.

c Your doctor did not accept assignment for this service. Under Federal law, your doctor cannot charge more than $39.02. If you have already paid more than this amount, you are entitled to a refund from the provider.

Deductible Information:

You have met the Part B deductible for 2006.

General Information:

You have the right to make a request in writing for an itemized statement which details each Medicare item or service which you have received from your physician, hospital, or any other health supplier or health professional. Please contact them directly, in writing, if you would like an itemized statement.

Compare the services you receive with those that appear on your Medicare Summary Notice. If you have questions, call your doctor or provider. If you feel further investigation is needed due to possible fraud and abuse, call the phone number in the Customer Service Information Box.

Appeals Information – Part B

If you disagree with any claims decisions on this notice, your appeal must be recieved by November 1, 2006. Follow the instructions below:

1) Circle the item(s) you disagree with and explain why you disagree.

2) Send this notice, or a copy, to the address in the “Customer Service Information” box on Page 1. (You may also send any additional information you may have about your appeal.)

3) Sign here _______________________________ Phone number ______________________

Revised 08/06

July 1, 2006

MEDICARE PART B MEDICAL INSURANCE: Medicare Part B helps pay for doctors’ services, diagnostic tests, ambulance services, durable medical equipment, and other health care services. Medicare Part 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. You will be sent a separate notice if you received Part A services or any outpatient facility services.

MEDICARE ASSIGNMENT: Medicare Part B claims may be assigned or unassigned. Providers who accept assignment agree to accept the Medicare approved amount as total payment for covered services. Medicare pays its share of the approved amount directly to the provider. You may be billed for unmet portions of the annual deductible and the coinsurance. You may contact us at the address or telephone number in the Customer Service Information box on the front of this notice for a list of participating providers who always accept assignment.

You may save money by choosing a participating provider.

Doctors who submit unassigned claims have not agreed to accept Medicare’s approved amount as payment in full.

Generally, Medicare pays you 80% of the approved amount after subtracting any part of the annual deductible you have not met. A doctor who does not accept assignment may charge you up to 115% of the Medicare approved amount. This is known as the Limiting Charge. Some states have additional payment limits. The NOTES section on the front of this notice will tell you if a doctor has exceeded the Limiting Charge and the correct amount to pay your doctor under the law.

YOUR RESPONSIBILITY: The amount in the You May Be Billed column is your share of cost for the services shown on this notice. You are responsible for:

• annual deductible: taken from the first Medicare Part B approved charges each calendar year,

• coinsurance: 20% of the Medicare approved amount, after the deductible has been met for the year,

• the amount billed, up to the limiting charge, for unassigned claims, and

• charges for services/supplies that are not covered by Medicare. You may not have to pay for certain denied services. If so, a NOTE on the front will tell you.

If you have supplemental insurance, it may help you pay these amounts. If you use this notice to claim supplemental benefits from another insurance company, make a copy for your records.

WHEN OTHER INSURANCE PAYS FIRST: All Medicare payments are made on the condition that you will pay Medicare back if benefits could be paid by insurance that is primary to Medicare. Types of insurance that should pay before Medicare include employer group health plans, no-fault insurance, automobile medical insurance, liability insurance and workers’ compensation. Notify us right away if you have filed or could file a claim with insurance that is primary to Medicare.

YOUR RIGHT TO APPEAL: If you disagree with what Medicare approved for these services, you may appeal the decision. You must file your appeal within 120 days of the date you receive this notice. Unless you show us otherwise, we assume you received this notice 5 days after the date of this notice. Follow the appeal instructions on the front of the last page of the notice. If you want help with your appeal, a friend or someone else can help you. Also, groups such as legal aid services may provide free assistance. To contact us for the names and telephone numbers of groups in your area, please see our Customer Service Information box on the front of this notice.

HELP STOP MEDICARE FRAUD: Fraud is a false representation by a person or business to get Medicare payments. Some examples of fraud include:

• offers of goods or money in exchange for your Medicare Number,

• telephone or door-to-door offers for free medical services or items, and

• claims for Medicare services/items you did not receive.

If you think a person or business is involved in fraud, you should call Medicare at the Customer Service telephone number on the front of this notice.

INSURANCE COUNSELING AND ASSISTANCE:

Insurance Counseling and Assistance programs are located in every State. These programs have volunteer counselors who can give you free assistance with Medicare questions, including enrollment, entitlement, Medigap, and premium issues. If you would like to know how to get in touch with your local Insurance Counseling and Assistance Program Counselor, please call us at the number shown in the Customer Service Information box on the front of this notice.

IMPORTANT INFORMATION

ABOUT YOUR MEDICARE PART B MEDICAL INSURANCE BENEFITS

For more information about services covered by Medicare, please see your Medicare Handbook.

Centers for Medicare & Medicaid Services