Eligibility Results for Date of Service: 08/06/2007 | |||
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Patient Name, Address (If Available), HIC Number, Date of Birth, & Date of Death (If Deceased) | ||
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PATIENT INFORMATION | |||
PUBLIC, JOHN Q 3720 Oceanside Road West Oceanside NY, 11572 |
HIC Number: 123456789A Date of Birth: 01/15/1935 Date of Death: LIVING |
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Part B Eligibility Status: Green = IS Eligible, Yellow = Eligible but has HMO/MSP, Red = Not Eligible (Inactive/Deceased) Deductible Remaining Effective/Termination Dates |
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MEDICARE PART B INFORMATION | |||
Patient IS eligible for MEDICARE PART B | |||
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No Other Information Available |
Additional Part B Benefit Info Also Displays HMO/MSP Name & Address Please Note: HMO/MSP Address Is As Provided By CMS And May Be Out of Date Please check with the carrier before sending claims |
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Part A Eligibility Status: Green = IS Eligible, Yellow = Eligible but has HMO/MSP, Red = Not Eligible (Inactive/Deceased) Deductible Remaining Effective/Termination Dates |
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MEDICARE PART A INFORMATION | |||
Patient IS eligible for MEDICARE PART A | |||
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Lifetime Reserve Days Remaining:60 (Actual) Home Health Care Start Date:07/04/2007 End Date Date:09/01/2007 Provider:Palmetto GBA Prov ID:107651 |
SNF Days Remaining:20 Date of Earliest Billing Action:07/04/2007 Date of Latest Billing Action:07/17/2007 SNF Co-Insurance Days Remaining:80 Amount Per Day:124.00 Date of Earliest Billing Action:07/04/2007 Date of Latest Billing Action:07/17/2007 Hospital Days Remaining:54 Date of Earliest Billing Action:07/04/2007 Date of Latest Billing Action:07/17/2007 Hospital Co-Insurance Days Remaining:30 Amount Per Day:248.00 Date of Earliest Billing Action:07/04/2007 Date of Latest Billing Action:07/17/2007 |
Additional Part A Benefit Info | |
REPORT CREATED:08/06/2007 |
TRANSACTION #:782929 |
Date Transaction Was Made, Transaction ID (used for support) |
Eligibility Results for Date of Service: 08/06/2007 | |||
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Same As Example #1 | ||
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PATIENT INFORMATION | |||
PUBLIC, JOHN Q 3720 Oceanside Road West Oceanside NY, 11572 |
HIC Number: 123456789A Date of Birth: 01/15/1935 Date of Death: LIVING |
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Note that the Bar is Yellow to indicate that the patient is enrolled in a MAP/HMO Plan |
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MEDICARE PART B INFORMATION | |||
Patient is enrolled in a Medicare Advantage Plan (HMO/MCO) | |||
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MAP/MCO Info Indemnity FIRST HEALTH LIFE AND HEALTH INSURA 3200 HIGHLAND AVE DOWNERS GROVE, IL 605151223 ID Code:H0846 006 Effective Date:04-01-2008 |
Additional Part B Benefit Info Also Displays HMO/MSP/PFFS/Other Insurance Name & Address Please Note: HMO/MSP Address Is As Provided By CMS And May Be Out of Date Please check with the carrier before sending claims |
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Part A Eligibility Status: Green = IS Eligible, Yellow = Eligible but has HMO/MSP, Red = Not Eligible (Inactive/Deceased) Deductible Remaining Effective/Termination Dates |
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MEDICARE PART A INFORMATION | |||
Patient is enrolled in a Medicare Advantage Plan (HMO/MCO) | |||
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Lifetime Reserve Days Remaining:60 (Actual) Home Health Care Start Date:07/04/2007 End Date Date:09/01/2007 Provider:Palmetto GBA Prov ID:107651 |
SNF Days Remaining:20 Date of Earliest Billing Action:07/04/2007 Date of Latest Billing Action:07/17/2007 SNF Co-Insurance Days Remaining:80 Amount Per Day:124.00 Date of Earliest Billing Action:07/04/2007 Date of Latest Billing Action:07/17/2007 Hospital Days Remaining:54 Date of Earliest Billing Action:07/04/2007 Date of Latest Billing Action:07/17/2007 Hospital Co-Insurance Days Remaining:30 Amount Per Day:248.00 Date of Earliest Billing Action:07/04/2007 Date of Latest Billing Action:07/17/2007 |
Additional Part A Benefit Info | |
REPORT CREATED:08/06/2007 |
TRANSACTION #:782929 |
Date Transaction Was Made, Transaction ID (used for support) |
Eligibility Results for Date of Service: 08/06/2007 | |||
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Same As Example #1 | ||
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PATIENT INFORMATION | |||
PUBLIC, JOHN Q 3720 Oceanside Road West Oceanside NY, 11572 |
HIC Number: 123456789A Date of Birth: 01/15/1935 Date of Death: LIVING |
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Eligibility Status Note that the Bar is Red to indicate that the patient is not enrolled in Medicare |
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MEDICARE PART B INFORMATION | |||
Patient IS NOT eligible for Medicare PART B | |||
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No Other Information Available |
Additional Part B Benefit Info | ||
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Eligibility Status Note that the Bar is Red to indicate that the patient is not enrolled in Medicare |
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MEDICARE PART A INFORMATION | |||
Patient IS NOT eligible for MEDICARE PART A | |||
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No Other Information Available |
Additional Part A Benefit Info | ||
REPORT CREATED:06/06/2008 |
TRANSACTION #:782929 |
Date Transaction Was Made, Transaction ID (used for support) |