By clicking on the links on the Medicare Summary Notice below, you can view each field.

HCFA Medicare Summary Notice

Health Care Financing Administration

January 13, 2001

Daisy M. Duck
2000 Brookside
Yourtown, PA 19999-9991

HELP STOP FRAUD: Report Medicare fraud by
calling the Inspector General's Fraud Hotline at 1-800-447-8477.

(1)CUSTOMER SERVICE INFORMATION

Your Medicare Number: 111-23-4569A

If you have questions, write or call:
Highmark Medicare Services
P. O. Box 890413
Camp Hill, PA 17089-0413

Service Code: 00865
Callers In PA: 1-800-633-4227
TTY for Hearing Impaired: 1-800-242-8471

Business Hours: M - F 9:00 AM - 4:30 PM EST

(2) This is a summary of claims processed on 01/11/2001.

Note: If there are multiple claims printed on a MSN, there may be a range date in this field.

PART B MEDICAL INSURANCE - ASSIGNED CLAIMS

Note *

(3)
Dates
of
Service

(4)
Services Provided

(5)
Amount
Charged

(6)
Medicare
Approved

(7)
Medicare
Paid
Provider

(8)
You
May Be
Billed

(9)
See
Notes
Section

(10) Claim Number 11-00101-722-310
(11) Doctor's Office, PC, Ste 10	b.c
1800 Center St., Ridley Park, PA 19078-2210
Dr. Green, John C., M.D. (12) Referred by: Robert Brown, M.D.

01/08/01

1 Office /outpatient visit, est (99242)

$55.00

$53.58

$0.00

$53.58

(13)Notes Section:

This approved amount has been applied toward your deductible.
As requested, this is a duplicate copy of your Medicare Summary Notice.
This information is being sent to Medicaid. They will review it to see if additional benefits can be paid.

THIS IS NOT A BILL - Keep this notice for your records

(14) Deductible Information:

You have now met $53.58 of your $100.00 Part B deductible for 2001.

(15) General Information:

If you have questions about this notice, call Highmark Medicare Services at 1-800-633-4227, select option 3 and then enter our service code 00865. If using a telecommunications device for the deaf (TDD), please call 1-800-242-8471. When writing to us, please include your telephone number.

To obtain claim, deductible or eligibility status, try our Automated Response Unit (IVR). If you have touch tone service, and live within PA, dial 1-800-633-4227. If you live outside of PA, dial 1-800-382-1274.

For important Medicare facts or information on how to appeal this claim, please see the last page of this notice or call 1-800-633-4227, select option 3 and enter our service code 00865. Additional Medicare information can be found on our web site at www.hgsa.com.

If you change your address, please contact the Social Security Administration at 1-800-772-1213.

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.

(16) Appeals Information - Part B

If you disagree with any claims decision on this notice, you can request an appeal by July 18, 2001. 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.

3. Sign here ____________________________________ Phone number (_____)______________________

(17) IMPORTANT INFORMATION

ABOUT YOUR MEDICARE PART B MEDICAL INSURANCE BENEFITS

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

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: the first $100 of 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 amount. 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 worker's 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 6 months of the date of this notice. Follow the appeal instructions on the front of the last page of this notice. If you want help with your appeal, you can have a friend or someone else help you. There are also groups, such as legal aid services, that will provide free advisory services if you qualify. You may contact us for the names and telephone numbers of groups in your area. To contact us, please see our Customer Service Information box on the front of this Summary 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 of free medical services or items, and
claims for Medicare services or 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.

Health Care Financing Administration

Field Descriptions

Customer Service Information - This area contains your Medicare number as well as the name, address and telephone number of the carrier that processed your claim.
Summary date- This area contains the date(s) the claim(s) finished processing.

Note: Although the indicators for the following fields are located at the top of this area, the information pertaining to these indicators is located beneath the provider name and address.
Dates of Service - This area lists the date(s) of service(s).
Services Provided - This area provides a description of the service(s) and procedure code your provider billed Medicare.
Amount Charged - This area lists the amount(s) your provider billed for each service.
Medicare Approved - This area shows the amount(s) that Medicare allows for the service(s) that were provided to you.
Medicare Paid Provider - This field gives the amount(s) that Medicare paid for your service(s). This amount is generally 80%* of the approved amount.

* In certain situations, Medicare may pay more or less than the standard 80% of the approved charges. For additional information, please refer to your Medicare Handbook.
You May Be Billed - This field will show the amount(s) your provider can bill you. This is usually 20%* of the approved amount, deductible, and any non-covered charges.

* See item 17 below.
See Notes Section - This field contains an alpha note indicator. An explanation of each indicator is located in the notes section.

Note: See item 13 below
Claim Number - This is the number that your Medicare carrier uses to identify the claim.
Provider Information - This area shows the name and address of the provider who submitted a claim on your behalf. The address shown is the billing address which may be different from where you received the service(s).
Referred by - This area gives the name of the physician who ordered the service(s) for you.

Note: The referring physician has no bearing on how your claim is paid. This is the name that the billing provider reports on his claim when certain service(s) are billed to Medicare.
Notes Section - This area provides a detailed explanation of how your claim was processed. This usually includes deductible information (if applied) as well as an explanation of why your claim may have denied.
Deductible Information - This area provides the deductible amount you have satisfied for the calendar year.
General Information - This section provides important Medicare news and information. It provides our telephone number, information about our automated response unit, privacy information, etc.
Appeals Information - This field explains how to request an appeal if you disagree with our claim decision. For additional information concerning your appeal rights, refer to Important Information section on the back of the first page of your Medicare Summary Notice.

Note: See item 17 below.
Important Information - This section appears on the back of page 1 of your summary notice. This area explains Part B Medicare insurance, Medicare assignment, your responsibility, etc.

For a detailed explanation of the Medicare Program, please refer to your Medicare and You handbook.

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