User manual BRINKS SAFE MODEL 5050

[. . . ] $19 Total paid by Medicare & supplemental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $95 Patient responsibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $14. 25 (Patient responsibility if no supplemental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $33. 25) Are there services for which Mayo Clinic must accept assignment from Medicare?Those services are: • Clinical laboratory tests covered by Medicare • Services provided by nonphysician practitioners (such as physician assistants, nurse anesthetists, etc. ) • Ambulatory surgery center facility fees • Covered drugs and biologicals Mayo also must accept assignment if Medicaid is your secondary insurance. Medicare Advantage Plans (MAPs) Mayo Clinic’s campus in Florida does not participate in any Medicare Advantage Plans offered by private insurance companies. We only see patients enrolled in the traditional or original Medicare program. 1 What to expect from Mayo Clinic billing 1. Mayo Clinic in Jacksonville, Fla. , automatically bills Medicare for services you have received. [. . . ] • When you receive the Medicare Summary Notice for those services from Medicare, enter the Medicare-approved amount under column C and the Medicare payment under column D. • If you have supplemental insurance and you have sent in your claim, you will receive an Explanation of Benefits (EOB) (Example 5 on Page 11) from the insurer. From this EOB, enter the payment for each charge under column E. • If a portion of the charge is adjusted by Mayo Clinic for any reason, enter the amount under column F. • Now, subtract columns D, E and F (if applicable) from column B to compute your out-of-pocket responsibility. • Add columns D, E and G and enter the total in column H. The amount under H is due to Mayo Clinic. • Every charge on your Mayo Clinic statement should match the charges on your worksheet. If a payment is missing from your worksheet, please call Medicare at (800) 633-4227 to determine if the claim has been processed. • If a charge is denied by Medicare or your supplemental insurer, or if the Medicare Summary Notice states that you are not responsible for the charge, please call Mayo Clinic at (904) 953-7058 for adjustment or claim resubmission. You also can write to us at Mayo Clinic, Patient Financial Services, 4500 San Pablo Road, Jacksonville, FL 32224. Please include a copy of the Medicare Summary Notice referring to the denied charge. • To appeal a denied charge when Medicare states that you are responsible for the charge, follow the instructions under “Appeals Information” on the last page of your Medicare Summary Notice. You also can call Medicare at (800) 633-4227. 3 About noncovered services Medicare considers some services to be routine or noncovered. A few examples are: eye refraction, foot care, hearing aids, cosmetic surgery, routine screenings and annual checkup visits. You will be financially responsible for these services. In addition, there are other services for which Medicare will determine payment based upon your diagnosis. During your clinic visit, you may have been asked to sign an Advanced Beneficiary Notice or ABN (Example 6 on Page 12) notifying you that one or more scheduled services may not be covered. Any questions regarding a specific service should be directed to Medicare at (800) 633-4227. For more information Mayo Clinic in Jacksonville, Fla. Patient Financial Services: (904) 953-7058 mcjmedicarehelp@mayo. edu Medicare Federal Government • 800-MEDICARE [(800) 633-4227] • Website: medicare. gov • Medicare and You 2006 (CMS Publication # 10050) Florida • Medicare Part B Customer Service: (800) 633-4227 • Hearing Impaired: (800) 486-2048 • Web site: medicarefla. com • Railroad Retirement Board: (800) 808-0772 Social Security Administration • (800) 772-1213 • Hearing Impaired: (800) 325-0778 4 Example 1 (Red & White Form) 5 Example 2 John K. Doe 123 Anywhere Your City, FL 11111 SAMPLE 6 Example 2 John K. Doe 5-572-792 8323 SAMPLE 7 Example 3 John K. [. . . ] I cannot appeal if Medicare is not billed OPTION 3. I don’t want the _______________ listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. Additional Information: This notice gives our opinion, not an official Medicare decision. [. . . ]