MEMO OF THE MONTH
MEMO OF THE MONTH YOUR EXPLANATION OF MEDICARE BENEFITS READ THIS NOTICE CAREFULLY AND KEEP IT FOR YOUR RECORDS P:)1.1e 1 o THIS IS NOT A SILL HE: Al TH CANE FINANCING AOMINIS1RATION DATE;...
...You can get more information by calling the number shown above...
...See item 4 on the back...
...MEMO OF THE MONTH YOUR EXPLANATION OF MEDICARE BENEFITS READ THIS NOTICE CAREFULLY AND KEEP IT FOR YOUR RECORDS P:)1.1e 1 o THIS IS NOT A SILL HE: Al TH CANE FINANCING AOMINIS1RATION DATE...
...Contact Empire Blue Cross and Blue Shield MEDICARE PART B 622 Third Avenue New York, New York 10017 Telephone (See item 1 on back) Local (212) 490-4444 Toll Free 1-800-442-8430 Assignment was not taken on your claim (Control Number 87-023-660-78-1-00) for $0.01...
...13, 1987 AMELIA STILLMAN 72 MAPLE RD CORNWALL ON HUDSON NY 12E20-1801 Need Help...
...Medicare denied payment for the service(s) reported...
...Billed Approved 1 Servace(s) Reported Jan 23,1987 We dad not consider this for payment because you or Your Doctor/Supplier dad not send the additional information we asked for...
...IMPORTANT: If you do not aciee with the amounts approved you may ask fur a re y,Pw To oo this von init,t :rule to us before Se p . 13, 1 987 (See item 1 on the back I DO YOU HAVE A QUESTION ABOUT THIS NOTICE...
...If yon beheve Medicare paid for a service you did not or there is an error contact us onmethatety Always give us Your Health Insurance Claim No 119-22-2640 8 Claim Control No 87-023-660-78-1-00...
...See the back of this notice for an explanation of assignment...
...0.01 $0.00 Next time you request payment, use your Medicare number as at as shown on this notice, Participating doctors and suppliers always accept assignment of Medicare claims...
...Payment can be requested again by sending us another claim form and all the information...
Vol. 19 • November 1987 • No. 10
