Your Medicare claims for the January 21, 2020 visit, in plain words
What you need to do
- Do not pay the doctor yet. Medicare sent this claim to your extra insurance, Wellmark BlueCross BlueShield of North Carolina. Wait to see what that plan pays before you pay anything.
- Decide whether to appeal the denied service by July 13, 2021. Medicare denied the skin-growth removal, so the doctor can bill you the full $68.56 for it. If you disagree, you can appeal in writing. Your appeal must reach Medicare by July 13, 2021.
- Check that this claim is real (see the box below).
If you do nothing else: wait for your Wellmark BlueCross BlueShield plan to pay. To fight the denied service, do not miss the July 13, 2021 appeal deadline.
Did you see Dr. Secosan on January 21, 2020? Check that you know this doctor and that you had this visit. Fraud can look like a bill for a service you never got, or an offer of "free" medical services. If something here is wrong, report it to Medicare at 1-800-MEDICARE (1-800-633-4227). If your tip helps uncover fraud, you may qualify for a reward.
The one deadline that matters
Appeal by July 13, 2021. Medicare denied one service on this notice (the skin-growth removal, $68.56). If you want to challenge it, your written appeal must reach Medicare by July 13, 2021. This is 120 days from the date on this notice. There is no cost to appeal, and it can be worth doing.
The step-by-step appeal instructions and mailing address are in "How to appeal the denied service" below.
Where the $90.15 comes from
The $90.15 is two separate things. One is your normal share of a service Medicare approved. The other is a service Medicare did not approve at all.
The $21.59 is your 20 percent share of the eye exam Medicare approved. The $68.56 is the full cost of the skin-growth removal Medicare denied. Your Medigap plan may pay part of the $90.15, so wait before you pay.
See the full claim, line by line
Visit to Craig I. Secosan, M.D. (Looking Glass Eye Center) on January 21, 2020. Claim number 02-10195-592-390.
| Service | Doctor charged | Most you may be billed |
|---|---|---|
| Eye and medical exam (code 92014) — approved | $143.00 | $21.59 |
| Skin-growth removal (code 17000) — denied | $68.56 | $68.56 |
| Total | $211.56 | $90.15 |
For the approved eye exam, Medicare approved $107.97 of the $143.00 charge and paid the doctor $86.38 (about 80 percent). That leaves $21.59 as your share. For the denied skin-growth removal, Medicare approved and paid $0.00, so the doctor can bill you the full $68.56.
What this means
For services it approves, Medicare usually pays 80 percent of the the set price Medicare allows for a service, often less than the doctor's charge. You or your extra insurance pay the other 20 percent. That 20 percent is your your share of a cost after Medicare pays its part, and here it is the $21.59 on the eye exam.
Doctors usually charge more than the Medicare-approved amount. Your share is figured from the approved amount, not the higher amount the doctor charged. On this claim the doctor charged $143.00 for the eye exam, Medicare approved $107.97, and your share was figured from the $107.97.
Before Medicare pays each year, you first pay a yearly the amount you pay for services each year before Medicare starts paying. You have paid $85.00 of your $147.00 Part B deductible for 2020, with $62.00 left to meet this year.
$85.00 of $147.00 paid · $62.00 left before Medicare pays more of your costs this year
About your extra insurance: Medicare already sent this claim to your extra insurance that helps pay costs Medicare leaves to you plan, Wellmark BlueCross BlueShield of North Carolina. It may pay all or part of the $90.15. Send any questions about your benefits to that plan.
More detail, if you want it
How to appeal the denied service
Medicare denied the skin-growth removal. Its reason: the information the doctor sent does not show this service was needed. If you disagree, you can appeal in writing. It is free.
Your written appeal must reach Medicare by July 13, 2021.
Follow these steps:
- Circle the service or claim you disagree with on your Medicare Summary Notice.
- Explain in writing why you disagree. Write it on the notice, or attach a separate page if you need more room.
- Fill in your full name, your telephone number, and your complete Medicare number, 1A23BC4DE56.
- Add any other information that supports your appeal. You can ask your doctor for records that help.
- Write your Medicare number on every page you send.
- Make copies of the notice and everything you send, for your own records.
- Mail it all to the Medicare Claims Office at the address printed on your paper notice.
Need help? Call 1-800-MEDICARE (1-800-633-4227) or your State Health Insurance Program before you file. You can also ask a family member or friend to act as your representative.
Your claim and visit details
Who to call
When you call 1-800-MEDICARE, say you are calling about "doctors services" and give your service code, 05535.
Reminders from Medicare
Your notice also carried two health reminders from Medicare. They are not about this claim.
- Get a pneumococcal shot. You may only need it once in your life. Ask your doctor about it. You pay nothing if your doctor accepts Medicare.
- Schedule a screening mammogram. Early detection is your best protection, and Medicare helps pay for screening mammograms.