Medicare Summary Notice Part B

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Part BWhat is in your“Medicare Summary Notice”?

Your New MSN: Part B Page 2Your New MSN for Part B – OverviewYour Medicare Part B MSN shows all of the servicesbilled by Medicare for doctors’ services, hospitaloutpatient care, home health care, preventive services,and other medical services.Medicare Summary NoticePage 2: Helpful tips on how to review your notice,Page 3: Your claims information,Jennifer WashingtonTHIS IS NOT A BILL Page 2 of 4Making the Most of Your MedicareThe Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid ServicesHow to Check This NoticeJENNIFER WASHINGTONTEMPORARY ADDRESS NAMESTREET ADDRESSCITY, ST 12345-6789THIS IS NOT A BILLNotice for Jennifer WashingtonEach Page with Specific Information:Page 1: Your dashboard, which is a summary ofyour notice,Page 1 of 4for Part B (Medical Insurance)Your Claims & Costs This PeriodMedicare Number1A23BC4DE56Did Medicare Approve All Services?Date of This NoticeMarch 1, 2020Claims ProcessedBetweenJanuary 1 –March 1, 2020Number of Services Medicare DeniedSee claims starting on page 3. Look for NO inthe “Service Approved?” column. See the lastpage for how to handle a denied claim.NOTotal You May Be Billed1Your deductible is what you must pay for most healthservices before Medicare begins to pay.Providers with Claims This PeriodJanuary 21, 2020Craig I. Secosan, M.D.Part B Deductible: You have now met 85.00 ofyour 147.00 deductible for 2020.Medicare covers many free or low-cost examsand screenings to help you stay healthy. For moreinformation about preventive services:Did you get the services listed? Do they matchthose listed on your receipts and bills? Talk to your doctor. Look at your “Medicare & You” handbook for acomplete list. Visit www.MyMedicare.gov for a personalized list.If you already paid the bill, did you pay theright amount? Check the maximum you may bebilled. See if the claim was sent to your Medicaresupplement insurance (Medigap) plan or otherinsurer. That plan may pay your share.How to Report Fraud 90.15Your Deductible StatusIf you think a provider or business is involved infraud, call us at 1-800-MEDICARE(1-800-633-4227).Some examples of fraud include offers for freemedical services or billing you for Medicare servicesyou didn’t get. If we determine that your tip led touncovering fraud, you may qualify for a reward.You can make a difference! Last year, Medicaresaved tax-payers 4.2 billion—the largest sum everrecovered in a single year—thanks to people whoreported suspicious activity to Medicare.Be Informed!Welcome to your new Medicare Summary Notice!It has clear language, larger print, and a personalsummary of your claims and deductibles. Thisimproved notice better explains how to get help withyour questions, report fraud, or file an appeal. It alsoincludes important information from Medicare!Medicare Preventive ServicesDo you recognize the name of each doctor orprovider? Check the dates. Did you have anappointment that day?Your Messages from MedicareGet a pneumococcal shot. You may only need it oncein a lifetime. Contact your health care provider aboutgetting this shot. You pay nothing if your health careprovider accepts Medicare assignment.To report a change of address, call Social Securityat 1-800-772-1213. TTY users should call1-800-325-0778.Early detection is your best protection. Scheduleyour mammogram today, and remember thatMedicare helps pay for screening mammograms.Want to see your claims right away? Access yourOriginal Medicare claims at www.MyMedicare.gov,usually within 24 hours after Medicare processes theclaim. You can use the “Blue Button” feature to helpkeep track of your personal health records.How to Get Help with Your Questions1-800-MEDICARE (1-800-633-4227)Ask for “doctors services.” Your customer-servicecode is 05535.TTY 1-877-486-2048 (for hearing impaired)Contact your State Health Insurance Program (SHIP)for free, local health insurance counseling. Call1-555-555-5555.Last page: Find out how to handle denied claims.¿Sabía que puede recibir este aviso y otro tipo de ayuda de Medicare en español? Llame y hable con un agente en �医疗保险,请先说“agent”, 然后说”Mandarin”.1-800-MEDICARE (1-800-633-4227)Bigger Print for Easy ReadingPage titles and subsection titles are now much larger.Using a larger print throughout makes the noticeeasier to read.Helpful Tips for Reading the NoticeThe redesigned MSN explains what you need to knowwith user-friendly language.Page 1Page 2Jennifer WashingtonTHIS IS NOT A BILL Page 3 of 4Your Claims for Part B (Medical Insurance)Your provider has agreed to accept this amount asfull payment for covered services. Medicare usuallypays 80% of the Medicare-approved amount.Definitions of ColumnsAmount Medicare Paid: This is the amountMedicare paid your provider. This is usually 80% ofthe Medicare-approved amount.Amount Provider Charged: This is your provider’sfee for this service.Medicare-Approved Amount: This is the amount aprovider can be paid for a Medicare service. It may beless than the actual amount the provider charged.Maximum You May Be Billed: This is the totalamount the provider is allowed to bill you, and caninclude a deductible, coinsurance, and other chargesnot covered. If you have Medicare SupplementInsurance (Medigap policy) or other insurance, itmay pay all or part of this amount.Craig I. Secosan, M.D., (555) 555-1234Looking Glass Eye Center PA, 1888 Medical Park Dr, Suite C, Brevard, NC 28712-4187ServiceApproved?Eye and medical examinationfor diagnosis and treatment,established patient, 1 or morevisits (92014)YesDestruction of skin growth (17000)NOTotal for Claim ovedAmountAmountMedicarePaid 143.00 107.97 86.38Get More DetailsFile an Appeal in WritingIf a claim was denied, call or write the providerand ask for an itemized statement for any claim.Make sure they sent in the right information. If theydidn’t, ask the provider to contact our claims officeto correct the error. You can ask the provider for anitemized statement for any service or claim.Follow these steps:Call 1-800-MEDICARE (1-800-633-4227) for moreinformation about a coverage or payment decisionon this notice, including laws or policies used tomake the decision.If You Disagree with a CoverageDecision, Payment Decision, or PaymentAmount on this Notice, You Can AppealJanuary 21, 2020Service Provided & Billing CodeMaximum SeeYou May NotesBe Billed Below 21.59Appeals must be filed in writing. Use the form tothe right. Our claims office must receive your appealwithin 120 days from the date you get this notice.July 13, 202168.560.000.0068.56 A 211.56 107.97 86.38 90.15 BIf You Need Help Filing Your AppealContact us: Call 1-800-MEDICARE or your StateHealth Insurance Program (see page 2) for helpbefore you file your written appeal, including helpappointing a representative.Ask a friend to help: You can appoint someone,such as a family member or friend, to be yourrepresentative in the appeals process.Find Out More About AppealsNotes for Claims AboveA This service was denied. The information provided does not support the need for this service or item.B Your claim was sent to your Medicare Supplement Insurance (Medigap policy), WellmarkBlueCross BlueShield of N. Carolina. Send any questions regarding your benefits to them.1 Circle the service(s) or claim(s) you disagreewith on this notice.2 Explain in writing why you disagree withthe decision. Include your explanation on thisnotice or, if you need more space, attach aseparate page to this notice.3 Fill in all of the following:Your or your representative’s full name (print)Your telephone numberYour complete Medicare numberWe must receive your appeal by:Call your provider: Ask your provider for anyinformation that may help you.Page 3THIS IS NOT A BILL Page 4 of 4How to Handle Denied Claims or File an AppealPart B Medical Insurance helps pay for doctors’services, diagnostic tests, ambulance services, andother health care services.Service Approved?: This column tells you if Medicarecovered this service.Jennifer WashingtonFor more information about appeals, read your“Medicare & You” handbook or visit us online atwww.medicare.gov/appeals.Last Page4 Include any other information you haveabout your appeal. You can ask your providerfor any information that will help you.5 Write your Medicare number on alldocuments that you send.6 Make copies of this notice and all supportingdocuments for your records.7 Mail this notice and all supportingdocuments to the following address:Medicare Claims Officec/o Contractor NameStreet AddressCity, ST 12345-6789

Your New MSN: Part B Page 3Page 1 – Your DashboardDHHS LogoThe redesigned MSN hasthe official Department ofHealth & Human Services(DHHS) logo.1Your InformationCheck your name and thelast 4 numbers of yourMedicare number, as wellas the date your MSN wasprinted and the dates of theclaims listed.Medicare Summary NoticePage 1 of 4for Part B (Medical Insurance)The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid ServicesJENNIFER WASHINGTONTEMPORARY ADDRESS NAMESTREET ADDRESSCITY, ST 12345-6789THIS IS NOT A BILLYour Deductible InfoYou pay a yearly deductiblefor services before Medicarepays. You can check yourdeductible information righton page 1 of your notice!Your Claims & Costs This PeriodMedicare Number1A23BC4DE56Did Medicare Approve All Services?Date of This NoticeMarch 1, 2020Claims ProcessedBetweenJanuary 1 –March 1, 2020Number of Services Medicare DeniedSee claims starting on page 3. Look for NO inthe “Service Approved?” column. See the lastpage for how to handle a denied claim.Total You May Be BilledNO1 90.15Your Deductible StatusYour deductible is what you must pay for most healthservices before Medicare begins to pay.3Total You May Be BilledA new feature on page 1,this summary shows yourapproved and denied claims,as well as the total you maybe billed.52Notice for Jennifer WashingtonTitle of your MSNThe title at the top of thepage is larger and bold.4Part B Deductible: You have now met 85.00 of your 147.00 deductible for 2020.Providers with Claims This PeriodJanuary 21, 2020Craig I. Secosan, M.D.Be Informed!Welcome to your new Medicare Summary Notice!It has clear language, larger print, and a personalsummary of your claims and deductibles. Thisimproved notice better explains how to get help withyour questions, report fraud, or file an appeal. It alsoincludes important information from Medicare!¿Sabía que puede recibir este aviso y otro tipo de ayuda de Medicare en español? Llame y hable con un agente en �医疗保险,请先说“agent”, 然后说”Mandarin”.1-800-MEDICARE (1-800-633-4227)Providers You SawCheck the list of dates andthe doctors you saw duringthis claim period.6Help in Your LanguageFor help in a language otherthan English or Spanish,call 1-800-MEDICARE andsay “Agent.” Tell them thelanguage you need for freetranslation services.7

Your New MSN: Part B Page 4Page 2 – Making the Most of Your MedicareSection TitleThis helps you navigate andfind where you are in thenotice. The section titles areon the top of each page.1How to CheckMedicare offers helpful tipson what to check when youreview your notice.2Jennifer WashingtonMaking the Most of Your MedicareHow to Get HelpThis section gives you phonenumbers for where to getyour Medicare questionsanswered.4Medicare Preventive ServicesDo you recognize the name of each doctor orprovider? Check the dates. Did you have anappointment that day?Medicare covers many free or low-cost examsand screenings to help you stay healthy. For moreinformation about preventive services:Did you get the services listed? Do they matchthose listed on your receipts and bills? Talk to your doctor. Look at your “Medicare & You” handbook for acomplete list. Visit www.MyMedicare.gov for a personalized list.If you already paid the bill, did you pay theright amount? Check the maximum you may bebilled. See if the claim was sent to your Medicaresupplement insurance (Medigap) plan or otherinsurer. That plan may pay your share.How to Report FraudHow to ReportHelp Medicare save moneyby reporting fraud!Preventive ServicesRemember, Medicarecovers many preventivetests and screenings tokeep you healthy.5How to Check This NoticeIf you think a provider or business is involved infraud, call us at 1-800-MEDICARE(1-800-633-4227).3THIS IS NOT A BILL Page 2 of 4Some examples of fraud include offers for freemedical services or billing you for Medicare servicesyou didn’t get. If we determine that your tip led touncovering fraud, you may qualify for a reward.You can make a difference! Last year, Medicaresaved tax-payers 4.2 billion—the largest sum everrecovered in a single year—thanks to people whoreported suspicious activity to Medicare.How to Get Help with Your Questions1-800-MEDICARE (1-800-633-4227)Ask for “doctors services.” Your customer-servicecode is 05535.TTY 1-877-486-2048 (for hearing impaired)Contact your State Health Insurance Program (SHIP)for free, local health insurance counseling. Call1-555-555-5555.Your Messages from MedicareGet a pneumococcal shot. You may only need it oncein a lifetime. Contact your health care provider aboutgetting this shot. You pay nothing if your health careprovider accepts Medicare assignment.To report a change of address, call Social Securityat 1-800-772-1213. TTY users should call1-800-325-0778.Early detection is your best protection. Scheduleyour mammogram today, and remember thatMedicare helps pay for screening mammograms.Want to see your claims right away? Access yourOriginal Medicare claims at www.MyMedicare.gov,usually within 24 hours after Medicare processes theclaim. You can use the “Blue Button” feature to helpkeep track of your personal health records.General MessagesThese messages get updatedregularly, so make sure tocheck them!6

Your New MSN: Part B Page 5Page 3 – Your Claims for Part B (Medical Insurance)Type of ClaimClaims can either beassigned or unassigned.1DefinitionsDon’t know what some ofthe words on your MSNmean? Read the definitionsto find out more.2Jennifer WashingtonTHIS IS NOT A BILL Page 3 of 4Your Claims for Part B (Medical Insurance)Part B Medical Insurance helps pay for doctors’services, diagnostic tests, ambulance services, andother health care services.Your provider has agreed to accept this amount asfull payment for covered services. Medicare usuallypays 80% of the Medicare-approved amount.Definitions of ColumnsAmount Medicare Paid: This is the amountMedicare paid your provider. This is usually 80% ofthe Medicare-approved amount.Service Approved?: This column tells you if Medicarecovered this service.Amount Provider Charged: This is your provider’sfee for this service.Medicare-Approved Amount: This is the amount aprovider can be paid for a Medicare service. It may beless than the actual amount the provider charged.Maximum You May Be Billed: This is the totalamount the provider is allowed to bill you, and caninclude a deductible, coinsurance, and other chargesnot covered. If you have Medicare SupplementInsurance (Medigap policy) or other insurance, itmay pay all or part of this amount.January 21, 2020Your VisitThis is the date you went toyour doctor. Keep your billsand compare them to yournotice to be sure you got allthe services listed.3ServiceApproved?Service Provided & Billing CodeEye and medical examinationfor diagnosis and treatment,established patient, 1 or morevisits (92014)YesDestruction of skin growth (17000)NOTotal for Claim ovedAmountAmountMedicarePaid 143.00 107.97 86.38Maximum SeeYou May NotesBe Billed Below 21.5968.560.000.0068.56 A 211.56 107.97 86.38 90.15 BApproved ColumnThis column lets youknow if your claim wasapproved or denied.5Service DescriptionsUser-friendly servicedescriptions will make iteasier for you to know whatyou were treated for.4Max You May Be BilledThis is the total amount theprovider is able to bill you.It’s highlighted and in boldfor easy reading.6Craig I. Secosan, M.D., (555) 555-1234Looking Glass Eye Center PA, 1888 Medical Park Dr, Suite C, Brevard, NC 28712-4187Notes for Claims AboveA This service was denied. The information provided does not support the need for this service or item.B Your claim was sent to your Medicare Supplement Insurance (Medigap policy), WellmarkBlueCross BlueShield of N. Carolina. Send any questions regarding your benefits to them.NotesRefer to the bottom of thepage for explanations of theservices you got.7

Your New MSN: Part B Page 6Last Page – How to Handle Denied ClaimsJennifer WashingtonGet More DetailsFind out your options onwhat to do about deniedclaims.1If You Decide to AppealYou have 120 days toappeal your claims.The date listed in the boxis when your appeal mustbe received by us.2How to Handle Denied Claims or File an AppealGet More DetailsFile an Appeal in WritingIf a claim was denied, call or write the providerand ask for an itemized statement for any claim.Make sure they sent in the right information. If theydidn’t, ask the provider to contact our claims officeto correct the error. You can ask the provider for anitemized statement for any service or claim.Follow these steps:Call 1-800-MEDICARE (1-800-633-4227) for moreinformation about a coverage or payment decisionon this notice, including laws or policies used tomake the decision.If You Disagree with a CoverageDecision, Payment Decision, or PaymentAmount on this Notice, You Can AppealAppeals must be filed in writing. Use the form tothe right. Our claims office must receive your appealwithin 120 days from the date you get this notice.If You Need HelpHelpful tips to guide youthrough filing an appeal.1 Circle the service(s) or claim(s) you disagreewith on this notice.2 Explain in writing why you disagree withthe decision. Include your explanation on thisnotice or, if you need more space, attach aseparate page to this notice.3 Fill in all of the following:Your or your representative’s full name (print)Your telephone numberYour complete Medicare numberWe must receive your appeal by:July 13, 20213THIS IS NOT A BILL Page 4 of 4If You Need Help Filing Your AppealContact us: Call 1-800-MEDICARE or your StateHealth Insurance Program (see page 2) for helpbefore you file your written appeal, including helpappointing a representative.Call your provider: Ask your provider for anyinformation that may help you.Ask a friend to help: You can appoint someone,such as a family member or friend, to be yourrepresentative in the appeals process.Find Out More About AppealsFor more information about appeals, read your“Medicare & You” handbook or visit us online atwww.medicare.gov/appeals.4 Include any other information you haveabout your appeal. You can ask your providerfor any information that will help you.5 Write your Medicare number on alldocuments that you send.6 Make copies of this notice and all supportingdocuments for your records.7 Mail this notice and all supportingdocuments to the following address:Medicare Claims Officec/o Contractor NameStreet AddressCity, ST 12345-6789Appeals FormYou must file an appeal inwriting. Follow the step-bystep directions when fillingout the form.4

The redesigned MSN explains what you need to know with user-friendly language. Medicare Summary Notice. Page 1 of 4. for Part B (Medical Insurance) The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid Services. Your Deductible Status. Your deductible is what

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