Medicare Summary Notice1
For Part A (Hospital Insurance)
Notice for Beneficiary Name
- Medicare Number
- dotted line
- Date of This Notice
- December 6, 20175
- dotted line
- Claims Processed Between
- June 15-
September 15, 20176
Your Deductible Status10 Your deductible is what you must pay for most health services before Medicare begins to pay.
Part A Deductible: You have now met your $1,316.00 deductible for inpatient hospital services for the benefit period that began May 27, 2017
Be Informed! Welcome to your new Medicare Summary Notice! It has clear language, larger print, and a personal summary of your claims and deductibles. This improved notice better explains how to get help with your questions, report fraud, or file an appeal. It also includes important information from Medicare!.
Your Claims & Costs for This Period
See page 2 for how to double-check this notice.
- Total You May Be Billed8
Facilities with Claims This Period9 June 18 – June 21, 2017
The codes and dollar amounts shown on this sample Medicare Summary Notice are for demonstration purposes only.
The dropdowns below include information sections from Medicare that you may find on your Medicare Summary Notice.
Making the most of your Medicare
Making the Most of Your Medicare
How to Check This Notice11
Do you recognize the name of each facility? Check the dates.
Did you get the claims listed? Do they match those listed on your receipts and bills?
If you already paid the bill, did you pay the right amount? Check the maximum you may be billed. See if the claim was sent to your Medicare supplement insurance (Medigap) plan or other insurer. That plan may pay your share.
How to Report Fraud12
If you think a facility or business is involved in fraud, call us at 1-800-MEDICARE (1-800-633-4227).
Some examples of fraud include offers for free medical services or billing you for Medicare services you didn’t get. If we determine that your tip led to uncovering fraud, you may qualify for a reward.
You can make a difference! Last year, Medicare saved tax-payers $4.2 billion—the largest sum ever recovered in a single year—thanks to people who reported suspicious activity to Medicare.
How to Get Help with Your Questions13
Ask for “hospital services.” Your customer-service code is 05535.
TTY 1-877-486-2048 (for hearing impaired)
Contact your State Health Insurance Program (SHIP) for free, local health insurance counseling. Call 1-555-555-5555.
Your Benefit Periods14
Your hospital and skilled nursing facility (SNF) stays are measured in benefit days and benefit periods. Every day that you spend in a hospital or SNF counts toward the benefit days in that benefit period. A benefit period begins the day you first receive inpatient hospital services or, in certain circumstances, SNF services, and ends when you haven’t received any inpatient care in a hospital or inpatient skilled care in a SNF for 60 days in a row.
- Inpatient Hospital: You have 56 out of 90 covered benefit days remaining for the benefit period that began May 27, 2017.
- Skilled Nursing Facility: You have 63 out of 100 covered benefit days remaining for the benefit period that began May 27, 2017.
- See your “Medicare & You” handbook for more information on benefit periods.
Your Messages from Medicare15
Get a pneumococcal shot. You may only need it once in a lifetime. Contact your health care provider about getting this shot. You pay nothing if your health care provider accepts Medicare assignment.
To report a change of address, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
Early detection is your best protection. Schedule your mammogram today, and remember that Medicare helps pay for screening mammograms.
Want to see your claims right away?
Access your Original Medicare claims at www.MyMedicare.gov, usually within 24 hours after Medicare processes the claim. You can use the “Blue Button” feature to help keep track of your personal health records.
Your Inpatient Claims for Part A (Hospital Insurance)
Your Inpatient Claims for Part A (Hospital Insurance)
Part A Inpatient 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.
Definitions of Columns
Benefit Days Used: The number of covered benefit days you used during each hospital and/or skilled nursing facility stay. (See page 2 for more information and a summary of your benefit periods.)
Claim Approved?: This column tells you if Medicare covered the inpatient stay.
Amount Medicare Paid: This is the amount Medicare paid your inpatient facility.
Maximum You May Be Billed: The amount you may be billed for Part A services can include a deductible, coinsurance based on your benefit days used, and other charges.
For more information about Medicare Part A coverage, see your “Medicare & You” handbook.
June 18 – June 21, 201716
Otero Hospital, (555) 555-1234
PO Box 1142, Manati, PR 00674
Referred by Jesus Sarmiento Forasti
Benefit Period starting May 27, 201717 4 days Yes $0.00 $4,886.98 $0.00 Total for Claim #2090540003410224 $0.00 $4,886.98 $0.00 A,B Benefit Period starting May 27, 201717 Total for Claim #2090540003410224 18
4 days 19
$0.00 $0.00 21
$4,886.98 $4,886.98 22
$0.00 $0.00 23
Notes for Claims Above25
A Days are being subtracted from your total inpatient hospital benefits for this benefit period. The “Your Benefit Periods” section on page 2 has more details. B $2,062.50 was applied to your skilled nursing facility coinsurance.
How to handle a denied claim or file an appeal
Get More Details
If a claim was denied, call or write the hospital or facility and ask for an itemized statement for any claim. Make sure they sent in the right information. If they didn’t, ask the facility to contact our claims office to correct the error. You can ask the facility for an itemized statement for any service or claim.
Call 1-800-MEDICARE (1-800-633-4227) for more information about a coverage or payment decision on this notice, including laws or policies used to make the decision.
If You Disagree with a Coverage Decision, Payment Decision, or Payment Amount on this Notice, You Can Appeal
Appeals must be filed in writing. Appeals must be filed in writing. Use the form to the right. Our claims office must receive your appeal within 120 days from the date you get this notice.
We must receive your appeal by:
January 21, 201427
If You Need Help Filing Your Appeal
Contact us: Call 1-800-MEDICARE or your State Health Insurance Program (see page 2) for help before you file your written appeal, including help appointing a representative.
Call your facility: Ask your facility for any information that may help you.
Ask a friend to help: You can appoint someone, such as a family member or friend, to be your representative in the appeals process.
Find Out More About Appeals
For more information about appeals, read your “Medicare & You” handbook or visit us online at www.medicare.gov/appeals.
1. Medicare Summary Notice
Medicare sends out statements like this example quarterly. If you don’t use any medical services in a particular three-month period, a statement won’t be sent. Your Medicare Summary Notice shows all services billed to your Medicare Part A account for inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care services. If you want to know your MSN’s contents before it arrives by mail, call the Medicare help line at 800-633-4227 or set up a private online account at MyMedicare.gov where you can view your records at any time.
Did you know that you can get your MSNs electronically (eMSNs). If you choose eMSNs, you’ll get a monthly email instead of having to wait 3 months for a paper copy in the mail.
2. Name and Address
If the name or address listed here is not correct, visit your local Social Security Administration office or call 800-772-1213 (TTY 800-325-0778 for the deaf or hard of hearing), weekdays from 7 a.m. to 7 p.m. You can also make the corrections online at SSA.gov.
3. This Is Not a Bill
Yes, that's right! Your Medicare Summary Notice is not a bill. It is a statement you should review for accuracy and keep for your personal records.
Very important: Never send payments to a health care facility or provider for charges listed on a Medicare Summary Notice until you've received a bill for the service directly from the facility. If you have already paid the facility, check to make sure that what you paid matches the amounts on your Medicare Summary Notice. If you paid more than needed, contact the facility's billing office to request a refund.
4. Your Medicare Number
This is the last four digits of your Medicare number. Protect it just as you would a credit card, bank account or Social Security number because, as you may have noticed, it is your Social Security number!
5. Date of This Notice
This is the date the notice was printed for mailing. Medicare Summary Notices are sent out four times a year — once a quarter — but you don’t necessarily have to wait for your notice to arrive in the mail. You can also check your account online at MyMedicare.gov. Claims typically appear on your electronic statement 24 hours after processing.
You can use the blue button on MyMedicare.gov to download and save your Part A & Part B claims information.
6. Claims Processed Between
This shows the dates of the three months in which claims were submitted on your Medicare account.
You’ll usually be able to see a claim within 24hrs after Medicare processes it.
7. Did Medicare Approve All Claims?
“Yes” means that Medicare covers this type of health care service. If you see “No” in this space, contact the health care facility and ask for an itemized statement. Also see the section How to Handle a Denied Claim at item No. 26. To challenge an unpaid charge, see “Appealing a Medicare Claim Decision."
Call 1-800-MEDICARE(1800-633-4227) for more information about a coverage or payment decision on this notice, including laws or policies used to make the decision.
8. Total You May Be Billed
This is the maximum amount the facility is able to bill you. It may include your Part A deductible, any coinsurance charges or any other expenses that Medicare does not cover. Compare your Medicare Summary Notice with the facility’s billing statement to make sure you are paying the correct amount. If you have already paid the facility, check to make sure that what you paid matches the amounts on your Medicare Summary Notice. If you paid more than needed, contact the facility's billing office to request a refund. Contact the facility if you spot errors in this section of your MSN. If you have a Medicare supplemental insurance policy (also called Medigap), Medicare will send this claim information directly to your insurance company. Your supplemental insurance may cover some or all of your out-of-pocket costs, depending on which policy you buy.
The summary shows your approved and denied claims, as well as the total you may be billed.
9. Facilities with Claims This Period
This is a list of the health care facilities that filed claims during this three-month billing period. Check to make sure you received care at those places on the dates listed here. If you did not, contact the facility’s billing department. If the facility cannot resolve your concerns, contact Medicare at 800-MEDICARE (800-633-4227).
10. Your Deductible Status
The Part A deductible of $1,316 is required for each hospital benefit period. A benefit period begins when you go into the hospital and ends when you have been out of the hospital for at least 60 days. If you return as an inpatient before the 60 days are up, the benefit period continues and another deductible is not required. But if you are hospitalized again after having been out for 60 days, you must pay another deductible in full (unless your Medigap policy covers it).
Part A Deductible: You have now met your $1,316 deductible for inpatient hospital services for the benefit period that began May 27, 2017.
11. How to Check This Notice:
This section gives you tips on how to carefully review the Medicare Summary Notice and things to looks for.
12. How to Report Fraud
This section gives tips on how to protect against Medicare fraud. For more information, visit AARP.org/FightFraud.
13. How to Get Help with Your Questions
State health insurance assistance programs (SHIPs) provide free, expert counseling on the phone or in person on Medicare issues. There’s a SHIP in every state, plus the District of Columbia, Puerto Rico and the U.S. Virgin Islands. To find the phone number of your SHIP, call the Eldercare Locator at 800-677-1116 or go online to www.shiptalk.org.
14. Your Benefit Periods
Your benefit period starts the day you first receive inpatient care in a hospital and ends when you have not received inpatient care in a hospital or skilled care in a skilled nursing facility for 60 days in a row. For more information, visit Ask Ms. Medicare.
15. Your Messages from Medicare
These messages change regularly.
16. Date of Service
This is the date or dates you were an inpatient at the hospital. To make sure this information is correct, you can check your calendar or the statement you were given by the facility. If you did not go to the hospital on the dates listed here, contact the facility filing the claim. It could be a mistake that the facility can easily correct. If it cannot resolve your concerns, contact Medicare at 800-MEDICARE (800-633-4227).
17. When your Benefit Period Starts
This shows when your current benefit period began.
18. Benefit Days Used
This is the number of benefit days you used during your hospital stay.
19. Service Approved?
“Yes” means that Medicare covers this type of health care service. If you see “No” in this space, contact the facility and ask for an itemized statement. Also see the section How to Handle a Denied Claim at item No. 26. To challenge an unpaid charge, see “Appealing a Medicare Claim Decision.”
20. Non-Covered Charges
For more about hospital charges Medicare does not cover, see "What Medicare Doesn't Cover."
21. Amount Medicare Paid
This is the amount Medicare paid the facility for this claim.
22. Maximum You May Be Billed
This is the maximum amount the facility can bill you. It may include your deductible ($1,216 in 2014 for each benefit period), your coinsurance charges for stays over 60 days in your benefit period or other charges that Medicare does not cover. Compare your Medicare Summary Notice with the facility’s billing statement to make sure you are paying the correct amount. Contact the facility if you spot errors in this section of your MSN.
23. See Notes Below
This column directs you to additional information about your claims. If there’s a letter in this column, refer to the Notes for Claim Above (described by item No. 25) at the bottom of the page for explanations of the claims on this Medicare Summary Notice.
24. Claim Number
Each claim made to your Medicare Part A account is assigned a distinct number. Refer to this claim number when speaking with the facility or Medicare.
25. Notes for Claim Above
Medicare uses this area to give you extra information about the claims listed in your Medicare Summary Notice. For instance, the message shown here is about benefit days and coinsurance.
26. How to Handle a Denied Claim or File an Appeal
Follow the steps in this section if Medicare denies payment for a claim you think should have been paid. Your appeal must be in writing. Print a copy of your online MSN at www.MyMedicare.gov, which includes this appeal page, or use the form you get in the mail with your paper MSN.
Complete the form by hand. Be sure to make a copy of everything you send to Medicare, and send it by recorded delivery or keep a note of when you mailed it.
For more information about appealing a denial and deadlines for filing, see Appealing a Medicare Claim Decision.
27. If You Disagree with a Coverage Decision, Payment Decision, or Payment Amount on this Notice, You Can Appeal
You have 120 days to appeal your claim. The date listed in the box is when your appeal must be received at the Medicare Claims Office. The address you should use is at the bottom of the form.
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