Form CMS-10453 Example of HMO Monthly Summary

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MONTHLY REPORT

Medical and Hospital Claims
Processed in June 2013
For Robert Daniel Smith
Member ID: 123-45-6789-0000

This is not a bill:
 This monthly report of claims we have processed tells
what care you have received, what the plan has paid, and
how much you have paid (or can expect to be billed).
 If you owe anything, your doctors and other health care
providers will send you a bill.
 This report covers medical and hospital care only. We
send a separate report on Part D prescription drugs.
 If you notice something suspicious that might be
dishonest billing, you can report it by calling 1-800MEDICARE (1-800-633-4227), 24 hours a day, 7 days a
week. (TTY users should call 1-877-486-2048.)

Birchwood Medicare Plus
An HMO with a Medicare contract. This plan is operated by Birchwood
Health Corporation, 1500 Springfield Drive, Anytown, CO 81110.
http://www.birchwood.com

Birchwood Member Services
If you have questions, call us: 1.866.000.1111
We are here 7 days a week from 8:00 am to 8:00 pm Eastern Time.
TTY / TDD only: 1.866.000.2222
Español: 1.866.000.3333
-------------------------This information is available for free in other languages. Please contact
Member Services at the number above. Member Services also has free
language interpreter services available for non-English speakers.
-------------------------Español: 1.866.000.3333
Esta información está disponible sin costo en otros idiomas. Para
obtener más información comuníquese con nuestro Servicio al Cliente al
número indicado arriba. El Departamento de Servicio al Cliente también
ofrece servicios gratuitos de interpretación de idiomas para
personas que no hablan inglés.

The benefit information provided is a brief summary, not a complete
description of benefits. For more information contact the plan. Benefits,
formulary, pharmacy network, premium, copayments, and coinsurance
may change on January 1 of each year.
H02231_00_9444 Accepted

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TOTALS
for medical and hospital claims

Amount
providers
have billed
the plan

Totals for this month (for claims
processed from June 1 to June 30, 2013)

Totals for 2013 (all claims processed
through June 30, 2013)

DEDUCTIBLE:
For most covered services,
the plan pays its share of the
cost only after you have paid
your yearly plan deductible.
As of June 30, 2013, you have
paid the full amount of your
$250 yearly plan deductible:

$0

$250
= your yearly
plan deductible

Total cost
(amount the plan
has approved)

Plan’s share

Your share

$810.00

$552.00

$377.60

$174.40

$1,640.00

$1,210.00

$828.20

$381.80

YEARLY LIMIT – this limit gives you financial protection
This limit tells the most you will have to pay in
2013 in “out-of-pocket” costs (copays,
coinsurance, and your deductible) for medical
and hospital services covered by the plan.
This yearly limit is called your “out-of-pocket
maximum.” It puts a limit on how much you
have to pay, but it does not put a limit on how
much care you can get. This means:

As of June 30, 2013, you have had $381.80 in outof-pocket costs that count toward your $3,400
out-of-pocket maximum for covered services.

$0

 Once you have reached your limit in outof-pocket costs, you stop paying.
 You keep getting your covered medical
and hospital services as usual, and the
plan will pay the full cost for the rest of
the year.

NOTE: To describe the services you received, this report uses billing codes and descriptions that were developed
and copyrighted by the American Medical Association (all rights reserved).

$3,400

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Details for claims processed in June 2013
Look over the information about your
claims – does it seem correct?

You have the right to make an appeal or complaint

 If you have questions or think there might
be a mistake, start by calling the doctor’s
office or other service provider. Ask them
to explain the claim.
 If you still have questions, call us at
Member Services (phone numbers are in
a box on page 1).

 Making an appeal is a formal way of asking us to
change our decision about your coverage. You can
make an appeal if we deny a claim. You can also
make an appeal if we approve a claim but you
disagree with how much you are paying for the
item or services. For information about making an
appeal, call us at Member Services (phone
numbers are in a box on page 1).

Maple Valley Ear, Nose, and Throat
Associates
Claim Number: 22-4178901-01-4000
(In-network provider)

Remember, this report is NOT A BILL:

Date of
service

Amount the
provider billed
the plan

Total cost
(amount the
plan approved)

Plan’s share

 If you have not already paid the
amount shown for “your share,”
wait until you get a bill from the
provider.
 If you get a bill that is higher than
the amount shown for “your share,”
call us at Member Services (phone
numbers are in a box on page 1).

Your share

Air and bone conduction assessment of
hearing loss and speech recognition
(billing code 92557)

4/8/13

$80.00

$76.00

$60.80

$15.20

Assessment of eardrum and muscle
function (billing code 92550)

4/8/13

$32.00

$24.00

$19.20

$4.80

Diagnostic examination of voice box using
flexible endoscope (billing code 31575)

4/8/13

$220.00

$140.00

$112.00

$28.00

TOTALS:

$332.00

$240.00

$192.00

$48.00
You pay 20% of the total amount
for specialty care

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Maria Sanchez, MD
Claim Number: 40-11144470-11-2000
(Out-of-network provider)

Date of
service

Established patient office or other
outpatient visit (billing code 99213)

Amount the
provider billed
the plan

Total cost
(amount the
plan approved)

Plan’s share

Your share

5/28/13

$80.00

$80.00
DENIED
(See below.)

$0.00

$80.00

TOTALS:

$80.00

$80.00
DENIED
(See below.)

$0.00

$80.00
Because the claim was denied,
you may be responsible for
paying this amount. Look below
for information about your
appeal rights.

Things to know about your denied claim:
 We have denied all or part of this claim and you have the
right to appeal. Making an appeal is a formal way of asking
us to change the decision we made to deny your claim. If we
agree to change our decision, it means we will approve the
claim rather than deny it, and we will pay our share.
 The provider can also make an appeal, and if this happens,
you may not have to pay. You may wish to contact the
provider to find out if they will ask us for an appeal. If the
provider properly asks for an appeal, you will not be
responsible for payment, except for the normal cost-sharing
amount, and you don’t need to make an appeal yourself.

 When we deny part or all of a
claim, we send you a letter
(“Notice of Denial of Payment”)
explaining why the service or item is
not covered. This letter also tells
what to do if you want to appeal
our decision and have us
reconsider.
 IMPORTANT: If you do not have this
letter, call us at Member Services
(phone numbers are in a box on
page 1).

 If you have questions or need
help with your appeal, you can
contact:
o Our Member Services (phone
numbers are in a box on
page 1)
o 1-800-MEDICARE (1-800-6334227), 24 hours a day, 7 days
a week. (TTY users should
call 1-877-486-2048.)

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Southside Memorial Hospital
Claim Number: 22-4178901-01-4000
(out-of--network provider)

Date of
service

Amount the
provider billed
the plan

Total cost
(amount the
plan approved)

Plan’s share

Your share

Mental status assessment (2014F-GC)
NOTE: The amounts are $0.00 because
the cost for this service or item is covered
under another part of this claim.

6/7/13

$0.00

$0.00

$0.00

$0.00

Electrocardiogram report (93010-GC)

6/7/13

$38.00

$32.00

$25.60

$6.40

Emergency department visit (billing code
99285-25GC)

6/7/13

$360.00

$200.00

$160.00

$40.00

TOTALS:

$398.00

$232.00

$185.60

$46.40
You pay 20% of the total cost for
emergency services

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Optional Supplemental Services: Details for claims processed in June 2013
(Amounts for optional supplemental services are not included in the totals shown on page 2)

Anita Fong, DDS
Claim Number: OSD00-211178-33-2121
Out-of-network provider of dental
services. Dental services are “optional
supplemental services.” These are extra
services for which you pay a separate
premium.

Date of
service

Oral exam (billing code OSD1444790

04/18/13

$200.00

$160.00

$80.00

$80.00

Dental x-rays (billing code OSD2457900)

04/18/13

$320.00

$240.00

$120.00

$120.00

$520.00

$400.00

$200.00

$200.00
You pay 50% of the total cost for
out-of-network dental care

TOTALS:

Amount the
provider billed
the plan

Total cost
(amount the
plan approved)

Plan’s share

Your share