Your Medicare visit summary, in very simple words
What you need to do
- Do not pay the doctor yet. You have a second health plan. Medicare sent this bill to that plan. Its name is Wellmark BlueCross BlueShield of North Carolina. Wait to see what it pays. Then pay only what is left.
- Decide by July 13, 2021 if you will fight the denied service. Medicare said no to a skin-growth removal. So the doctor can bill you the full $68.56. If you disagree, you can write to Medicare and fight it. Your letter must get there by July 13, 2021.
- Make sure this visit is real (see the box below).
If you do nothing else: wait for your Wellmark plan to pay. To fight the denied service, do not miss July 13, 2021.
Did you see Dr. Secosan on January 21, 2020? Make sure you know this doctor. Make sure you had this visit. Sometimes people cheat Medicare. They may bill for a visit you never had. They may offer free care that is not real. Does something look wrong? Call Medicare at 1-800-MEDICARE (1-800-633-4227). Your tip may earn you a reward.
The one date to watch
Fight the denied service by July 13, 2021. Medicare said no to one service, the skin-growth removal. That service costs $68.56. Do you want to fight it? Your letter must reach Medicare by July 13, 2021. That is 120 days after this notice. It costs nothing to fight it.
The steps and the mailing address are in the box below.
Where the $90.15 comes from
The $90.15 is really two things. One part is your share of a service Medicare approved. The other part is a service Medicare turned down.
An easy way to see it. Think of the visit as two jobs. Job one is an eye exam. Medicare approved it. Your share is $21.59. Job two is a skin-growth removal. Medicare said no. So you may owe the whole cost, $68.56. Add them up. $21.59 plus $68.56 is $90.15. That is the most you may owe. Your other health plan may pay part of it. 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 owe |
|---|---|---|
| Eye and medical exam (code 92014) — approved | $143.00 | $21.59 |
| Skin-growth removal (code 17000) — turned down | $68.56 | $68.56 |
| Total | $211.56 | $90.15 |
For the eye exam, Medicare set the price at $107.97. Medicare paid the doctor $86.38 of it. That left $21.59 as your share. Medicare turned down the skin-growth removal. So the doctor can bill you the full $68.56.
What this means
How your share was worked out
For a service it approves, Medicare pays most of the cost. Medicare pays 80 out of every 100 dollars. You pay the other 20 dollars. That 20 dollars is your share. On your notice, this share is called the small part of the cost you pay yourself.
Here is this visit as an example. Medicare set the eye exam price at $107.97. On your notice, this price is called the the price Medicare sets for a service. Medicare paid $86.38 of it. That is about 80 out of every 100 dollars. You are left with $21.59. That is your share.
What the doctor charged
Doctors often charge more than Medicare allows. Your share comes from the price Medicare allows. It does not come from the higher charge. For this visit, the doctor charged $143.00 for the eye exam. Medicare allowed only $107.97. Your share came from the $107.97.
What you pay first each year
Each year you pay some costs first. Then Medicare starts to pay. On your notice, this first part is called the the amount you pay each year before Medicare starts to pay. This year the amount is $147.00. You have paid $85.00 so far. You have $62.00 left to pay this year.
$85.00 of $147.00 paid · $62.00 left this year
About your other health plan. You have a second health plan. It helps pay costs that Medicare leaves to you. On your notice, this kind of plan is called a second plan that helps pay what Medicare does not. Your plan is Wellmark BlueCross BlueShield of North Carolina. Medicare already sent this bill to that plan. It may pay part or all of the $90.15. Ask that plan about your costs.
More detail, if you want it
How to fight the denied service (appeal)
Medicare said no to the skin-growth removal. Its reason: the notes do not show you needed it. Do you disagree? You can write to Medicare and fight it. This is called an appeal. It is free.
Your letter must reach Medicare by July 13, 2021.
Here are the steps.
- Circle the service you disagree with on your notice.
- Write why you disagree. Use the notice, or a separate page.
- Write your full name and your phone number. Add your Medicare number, 1A23BC4DE56.
- Add any papers that help. You can ask your doctor for records.
- Write your Medicare number on each page.
- Make a copy of it all, for yourself.
- Mail it to the Medicare Claims Office. The address is on your paper notice.
Need help? Call 1-800-MEDICARE (1-800-633-4227) or your State Health Insurance Program. You can also ask a family member or friend to help you.
Your claim and visit details
Who to call
When you call, say you are calling about "doctors services". Give your code, 05535.
Reminders from Medicare
Your notice also had two health tips from Medicare. They are not about this visit.
- Get a pneumococcal shot. You may need it just once in your life. Ask your doctor about it. You pay nothing if your doctor takes Medicare.
- Get a screening mammogram. Finding a problem early helps most. Medicare helps pay for it.