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1. ee TET a 2 2 SS ee pea a 20 x t 22 m HX 9 Payment Summary Form e REPORT NUMBER DATE 08 25 2010 CONTRACTOR MBDICARE SECONDARY PAYER RECOVERY CONTRACTOR BENEFICIARY NAME CASE ID BENEFICIARY LIABILITY DATE OF INCIDENT TOS ICN LINE PROCESSING PROVIDER DIAGNOSIS ICD FROM TO TOTAL REIMBURSED CONDITIONAL CONTRACTOR NAME DATE DATE CHARGES AMOUNT PAYMENT SERVICES 71 500209348051760 2 512 PAFFORD MEDICAL 72981 7295 11 26 2009 11 26 2009 24 00 16 66 16 66 SERVICES 71 500209350160300 1 512 HUGHES TOMMY 27651 11 26 2009 11 26 2009 364 93 132 01 132 01 71 500209355359580 1 512 SMITH ANDREA L 72981 27651 11 26 2009 11 27 2009 225 00 111 96 111 96 34590 4019 7 850 71 500209355359580 2 512 SMITH ANDREA 72981 27551 11 26 2009 11 27 2009 118 00 50 90 50 90 34590 4019 7 850 71 500209355052600 1 512 PAFFORD MEDICAL 70706 78009 11 27 2009 11 27 2009 625 00 155 10 155 10 SERVICES 71 500209355052600 2 512 PAFFORD MEDICAL 70706 78009 11 27 2009 11 27 2009 24 00 16 66 16 66 SERVICES 71 500210084308500 1 512 ADELEYE JAIYEO 70706 03 11 2010 03 11 2010 69 30 28 04 28 04 LA O 71 500210117067130 1 512 KELLOUGH KENNE 27651 5070 7 04 13 2010 04 13 2010 364 93 128 08 128
2. MED EXPRESS OF MISSISSPPI DIAGNOSIS ICD 6 5939 7852 7852 7852 5183 485 5183 485 5183 485 5183 485 5183 485 5183 485 5183 485 5183 485 5130 4019 48 21 70705 5130 4019 48 21 70705 4019 5130 7806 2859 48 6 5939 7806 2859 48 6 5939 7806 2859 48 6 5939 485 486 4380 V4989 7 1845 78002 4380 V4989 7 1845 78002 Payment Summary Form FROM DATE 09 18 2006 09 18 2006 09 18 2006 09 21 2006 09 21 2006 09 21 2006 09 21 2006 09 21 2006 09 21 2006 09 21 2006 09 21 2006 09 22 2006 09 22 2006 09 22 2006 10 01 2006 10 01 2006 10 04 2006 10 04 2006 10 06 2006 10 06 2006 TO DATE 09 18 2006 09 18 2006 09 18 2006 09 27 2006 09 27 2006 09 27 2006 09 27 2006 09 27 2006 09 27 2006 09 27 2006 09 27 2006 09 22 2006 09 22 2006 09 22 2006 10 06 2006 10 06 2006 10 06 2006 10 04 2006 10 06 2006 10 06 2006 CASE ID a RENE DATE 08 25 2010 00022 CASE TYPE LIABILITY DATE OF INCIDENT H TOTAL CHARGES 172 00 99 00 34 00 202 93 35 37 144 49 346 77 324 22 57 93 70 74 57 93 667 33 513 80 42 00 115 86 106 11 73 23 35 37 395 00 190 00 REIMBURSED CONDITIONAL AMOUNT PAYMENT 37 46 37 46 15 55 15 55 3 10 3 10 0 00 0 00 25 91 25 91 0 00 0 00 116 87 116 87 1 69 1 69 42 42 42 42 51 82 51 82 42 42 42 42 63 10 63 10 63 10 63 10 i 6 90 6 90 84 85 84 85 71 74 77
3. Spoke with BCRC Representative at a m or p m Date Received Rights And Responsibilities Letter The BCRC representative will take all of the information you have collected on your Client Information Worksheet Send Fax the BCRC the Proof of Representation OR Consent to Release Form All parties should receive the Rights and Responsibilities Letter within three 3 weeks of contacting the BCRC in step number 1 If you DO NOT receive the Rights And Responsibilities Letter within three 3 weeks call the BCRC at 1 855 798 2627 Inform the BCRC representative that you have NOT received the Rights and Responsibilities Letter the date you notified the BCRC and who you spoke to IF the BCRC needs any additional information and or documentation they will first attempt to contact you by phone however if they are unsuccessful they will mail you a letter You should receive the Conditional Payment Letter within sixty five 65 days of the date on the Rights And Responsibilities Letter Benefits Coordination amp Recovery Center Medicare MSP General Correspondence BCRC P O Box 138897 Non Group Health Plan NGHP Inquiries and Checks Oklahoma City OK 73113 8897 NGHP Fax 1 405 869 3307 P O Box 138832 Oklahoma City OK 73113 00012 MEDICARE Worksheet Additional Notes Client NAME MEDICARE 00013 MODEL LANGUAGE RO F REP TATION The language below sh
4. 276 51 Dehydration 530 81 Esophageal Reflux 707 06 Chron Ulc to Skin Ankle 276 51 Dehydration 780 60 Fever 276 51 Dehydration 780 60 Fever 276 51 Dehydration 780 60 Fever 276 51 Dehydration 780 60 Fever 707 13 Ulcer of Ankle 707 03 Chr Ulc Skin Low Back 290 30 Senile Demen w Delirium 335 21 Progress Musc Atrophy 718 45 Contx Joint Pelvic Thigh 707 03 Chr Ulc Skin Low Back 290 30 Senile Demen w Delirium 335 21 Progress Mus Atrophy 718 45 Contx Joint amp Pelvic Thigh 780 79 Other Mailaise Fatigue 780 60 Fever 780 79 Other Malaise Fatigue 780 60 Fever 276 51 Dehydration 276 51 Dehydration 530 81 Esophageal Reflux 707 09 Chronic Ulcer Unsp 780 60 Fever 276 51 Dehydration 1 65 1 65 7 69 7 69 66 33 121 76 13 56 24 73 82 58 34 55 5 62 45 26 1 66 1 66 2 46 1 65 1 65 7 69 7 69 66 33 121 76 13 56 24 73 34 55 34 55 34 55 5 62 5 62 5 62 135 49 135 49 23 11 23 11 1 66 1 66 12 11 2007 12 11 2007 12 11 2007 12 11 2007 12 11 2007 12 11 2007 12 11 2007 12 11 2007 12 11 2007 12 11 2007 12 11 2007 12 11 2007 12 11 2007 12 11 2007 12 11 2007 12 11 2007 12 17 2007 12 18 2007 12 18 2007 12 18 2007 12 18 2007 12 18 2007 12 18 2007 12 18 2007 12 18 2007 3 2 2008 3 2 2008 3 2 2008 3 2 2008 3 2 2008 3 2 2008 3 2 2008 3 2 2008 3 2 2008 3 3 2008 99644
5. 512 512 512 512 512 PROVIDER NAME SMITH ANDREA L SMITH ANDREA L WILLIAMS JASON R WILLIAMS JASON R PAFFORD MEDICAL SERVICES PAFFORD MEDICAL SERVICES PAFFORD MEDICAL SERVICES PAFFORD MEDICAL SERVICES WILLIAMS JASON R WILLIAMS JASON R SMITH ANDREA L SMITH ANDREA L 1749 4019 59 90 27651 V1259 1749 4019 59 90 27651 V1259 1749 4019 59 90 53081 27651 7806 78097 78097 27651 53081 7806 70709 70709 78009 78079 7808 78009 78079 7808 27651 2948 3 4590 4270 2948 27651 3 4590 4270 27651 V103 2 724 4019 599 27651 V103 2 Payment Summary Form FROM DATE 03 03 2008 03 03 2008 03 06 2008 03 06 2008 03 07 2008 03 07 2008 03 26 2008 03 26 2008 03 26 2008 03 26 2008 03 27 2008 03 27 2008 TO DATE 03 07 2008 03 07 2008 03 06 2008 03 06 2008 03 07 2008 03 07 2008 03 26 2008 03 26 2008 03 26 2008 03 26 2008 03 31 2008 03 31 2008 e e e DATE 08 25 201 0 CASE ID CASE TYPE LIABILITY DATE OF INCIDENT TOTAL REIMBURSED CONDITIONAL CHARGES AMOUNT PAYMENT 59 00 27 05 27 05 143 00 70 57 70 57 148 00 9 86 9 86 215 00 31 26 31 26 625 00 142 63 142 63 66 00 46 22 46 22 740 00 270 99 270 99 22 00 518 41 15 41 38 00 6 66 6 66 215 00 31 26 31 26 254 00 181 58 131 58 59 00 27 05 27 05 ea eme
6. REPORT NUMBER CONTRACTOR MEDICARE SECONDARY PAYER RECOVERY CONTRACTOR BENEFICIARY NAME BENEFICIARY HICN TOS 71 71 71 71 71 71 71 71 71 71 71 71 ICN 500206079083870 500206110160550 500206145165960 500206 165176050 500206201 157920 500206242251840 500206236179480 500206290220360 500206290220360 500206290220960 500206290220360 500206290220360 500206290220360 LINE PROCESSING CONTRACTOR 512 512 512 512 512 512 512 512 512 512 512 512 Payment Summary Form N e e e DATE 08 25 2010 CASE ID CASE TYPE LIABILITY i DATE OF INCIDENT SEEL PROVIDER DIAGNOSIS ICD FROM TO TOTAL REIMBURSED CONDITIONAL NAME DATE DATE CHARGES AMOUNT PAYMENT ES E WARRINGTON JAM 71940 03 17 2006 03 17 2006 85 00 60 14 60 14 ES E WARRINGTON JAM 71940 04 19 2006 04 19 2006 85 00 60 14 60 14 ES E WARRINGTON JAM 71940 05 24 2006 05 24 2006 85 00 60 14 60 14 ES E WARRINGTON JAM 71940 06 13 2006 06 13 2006 85 00 60 14 60 14 ES E WARRINGTON JAM 71940 07 19 2006 07 19 2006 85 00 60 14 60 14 ES E WHITMORE RMICH 7295 44020 08 11 2006 08 11 2006 96 00 25 71 25 71 AEL WARRINGTON JAM 71940 08 23 2006 08 23 2006 85 00 60 14 60 14 ES E OZUA EDWIN I 7806 2859 48 09 15 2006 09 30 2006 163 42 119 70 119 70 6 5939 OZUA EDWIN I 7806 2859 48 09 15 2006 09 30 2006 82 35 60 32 60 32 6 5939 OZUA EDWIN I 7806 2859 48 09 15 2006
7. since it is the Secretary who is seeking reimbursement A Medicare subscriber should not bear the burden of proving a negative Urso 309 Supp 2d at 260 00006 1 2 3 4 Other Options To Pay Medicare Lien These options are available before Final Judgment or Settlement THE SELF SERVICE OPTION is a means to obtain Conditional Payment Information via the telephone and without having to speak with a Customer Service Representative To use this option call 1 855 798 2627 and select the Self Service option When you use the Self Service option you will need the Case ID the beneficiary s Medicare number date of birth and last name SECTION 201 OF THE SMART ACT Use the Portal to determine the Final Demand First you must settle within one hundred twenty 120 days of filing and CMS will respond within sixty five 65 days If you dispute BCRC s amount you can challenge it and CMS must respond within eleven 11 days or the amount you claim will be automatically accepted If CMS does respond it will be placed on portal and you may appeal if you are not satisfied FIXED PERCENTAGE OPTION settled case meets certain eligibility criteria a beneficiary or his her representative may request that Medicare s demand amount be calculated using the Fixed Percentage Option The Fixed Percentage Option offers a simple straightforward process to obtain the amount due Medicare It eliminates time and resources ty
8. 08 TH W 8060 71 500210130271310 1 512 SMITH ANDREA L 78701 2900 4 04 14 2010 04 21 2010 254 00 141 11 141 11 019 486 5308 1 71 500210130271310 2 512 SMITH ANDREA L 78701 2900 4 04 14 2010 04 21 2010 59 00 28 38 28 38 019 486 5308 1 71 500210130271310 3 512 SMITH ANDREA L 78701 2900 4 04 14 2010 04 21 2010 59 00 28 38 28 38 019 486 5308 1 71 500210130271310 4 512 SMITH ANDREA L 78701 2900 4 04 14 2010 04 21 2010 59 00 28 38 28 38 m o Payment Summary Form 00028 DATE 08 25 2010 CONTRACTOR MEDICARE SECONDARY PAYER RECOVERY CONTRACTOR CASE ID i CASE TYPE LIABILITY DATE OF INCIDENT BENEFICIARY NAME BENEFICIARY HICN 4 TOS ICN LINE PROCESSING PROVIDER DIAGNOSIS ICD FROM TO TOTAL REIMBURSED CONDITIONAL CONTRACTOR NAME DATE DATE CHARGES AMOUNT PAYMENT 019 486 5308 1 71 500210130271310 5 512 SMITH ANDREA L 78701 2900 4 04 14 2010 04 21 2010 59 00 28 38 28 38 019 486 5308 71 500210130271310 6 512 SMITH ANDREA L 78701 2900 4 04 14 2010 04 21 2010 59 00 28 38 28 38 019 486 5308 1 71 500210130271310 7 512 SMITH ANDREA L 78701 2900 4 04 14 2010 04 21 2010 59 00 28 38 28 38 019 486 5308 1 71 500210130271310 8 512 SMITH ANDREA L 78701 2900 4 04 14 2010 04 21 2010 105 00 50 14 50 14 019 486 5308 1 71 500210148052340 1 512 PAFFORD MEDICAL 2948 V4984 7 04 21 2010 04 21 2010 625 00 150 58 150 58 SERVICES 0709 71 500210148052340 2 51
9. 11 17 2006 118 00 51 82 51 82 512 SMITH ANDREA L 27651 5990 10 24 2006 11 17 2006 649 00 285 03 285 03 512 SMITH ANDREA L 27651 5990 10 24 2006 11 17 2006 100 00 53 64 53 64 512 SMITH ANDREA 27651 0389 5 10 24 2006 10 24 2006 94 00 7 15 7 15 990 70707 512 SMITH ANDREA L 27651 0389 2 10 25 2006 10 25 2006 94 00 7 15 7 15 639 5990 512 SMITH ANDREA L 41400 0389 5 11 14 2006 11 14 2006 89 00 3 10 3 10 990 512 SMITH ANDREA L 41400 0389 5 11 14 2006 11 14 2006 128 00 15 55 15 55 990 512 SMITH ANDREA L 41400 0389 5 11 14 2006 11 14 2006 224 00 37 46 37 46 990 512 MED EXPRESS OF 71845 V4989 11 17 2006 11 17 2006 395 00 134 96 134 96 MISSISSPPI 4382 1 70700 512 MED EXPRESS OF 71845 V4989 11 17 2006 11 17 2006 19 00 14 67 14 67 MISSISSPPI 43821 70700 740 LABORATORY CORP 7079 01 22 2007 01 22 2007 43 05 12 03 12 03 ORATION OF AM 740 LABORATORY CORP 7079 01 22 2007 01 22 2007 138 00 28 89 28 89 71 741107039130830 TIED REPORT NUMBER CONTRACTOR MEDICARE SECONDARY PAYER RECOVERY CONTRACTOR BENEFICIARY NAME BENEFICIARY HICN EEE TT TE LS H TOS ZA 7i 71 71 71 71 71 71 71 71 71 71 Ta 74 ICN 741107039130830 500207 120080230 500207 120080230 500207 121053440 500207 121053440 500207298 144260 500207298 144260 500207298 144260 500207298 144260 500207298 144260 500207298 144260 500208 128 185400 500208 12
10. 2008 3 26 2008 3 26 2008 3 26 2008 3 26 2008 3 26 2008 3 26 2008 3 26 2008 3 26 2008 3 26 2008 3 26 2008 3 26 2008 3 26 2008 3 26 2008 3 26 2008 3 26 2008 3 26 2008 3 26 2008 3 26 2008 3 26 2008 3 27 2008 3 27 2008 3 27 2008 3 27 2008 3 27 2008 3 27 2008 3 27 2008 3 27 2008 3 27 2008 3 27 2008 3 27 2008 3 27 2008 3 27 2008 3 27 2008 3 27 2008 3 27 2008 3 27 2008 3 27 2008 993 6 46 22 270 99 15 41 6 66 31 26 131 58 27 05 27 05 27 05 70 57 Andrea L Smith Andrea L Smith Pafford Med Service Pafford Med Service Pafford Med Service Pafford Med Service Pafford Med Service Pafford Med Service Professional Clin Lab Professional Clin Lab Professional Clin Lab Jason R Williams Jason R Williams Jason R Williams Jason R Williams Pat S Burke Pat S Burke Pat S Burke Jason R Williams Jason R Williams Jason R Williams Jason R Williams Pafford Med Service Pafford Med Service Pafford Med Service Patford Med Service Tommy Hughes Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith 401 90 HTN Unsp 599 00 UTI 14 11 707 05 Chron Ulc of Skin Buttock 47 54 294 80 Mental D O Nos 707 09 Chronic Ulcer of Skin Unsp 47 54 707 05 Chron Ulc to Skin Buttock 5 13 294 80 Mental D O Nos 707 09 Chronic Ulcer to Skin Unsp 5 13 730 39 Periostitis Invol Mu
11. 74 53 64 53 64 25 91 25 91 134 96 134 96 i 139 38 139 38 REPORT NUMBER CONTRACTOR MEDICARE SECONDARY PAYER RECOVERY CONTRACTOR BENEFICIARY NAME BENEFICIARY HICN Payment Summary Form DATE 08 2 CASE ID CASE T YPE LIAB 00023 2010 LLITY DATE OF INCIDENT 01 01 2006 I n n TOS 71 71 71 71 71 71 TA 74 TA 71 F 71 71 T4 71 71 71 ICN 500206290172540 500206305 166830 500206349 128030 500206349309050 500206349309050 500206349309050 500206349309050 500206349309050 500206349309050 500206332170760 500206332170770 500207159057220 500207159057220 500207159057220 500206324053100 500206324053100 741107039130830 LINE pr PROCESSING PROVIDER DIAGNOSIS ICD FROM TO TOTAL REIMBURSEL CONDITIONAL CONTRACTOR NAME DATE DATE CHARGES AMOUNT PAYMENT M 512 WARRINGTON JAM 41400 71940 10 16 2006 10 16 2006 85 00 60 14 60 14 ES E 512 WADE TARENCE 27651 5990 10 23 2006 10 23 2006 347 55 116 12 116 12 512 BERRYHILL UR G V7281 0389 5 10 23 2006 10 23 2006 42 00 6 90 6 90 US D 990 512 SMITH ANDREA L 27651 5990 10 24 2006 11 17 2006 199 00 119 70 119 70 512 SMITH ANDREA L 27651 5990 10 24 2006 11 17 2006 413 00 181 38 181 38 512 SMITH ANDREA L 27651 5990 10 24 2006 11 17 2006 177 00 77 74 77 74 512 SMITH ANDREA L 27651 5990 10 24 2006
12. BCRC website http go cms gov cobro for all of the additional details You will find model language that can be used to elect this option as well as a special mailing address to ensure efficient processing How You Can Contact Us Please mail any documents to BCRC Fixed Percentage Option P O Box 138880 Oklahoma City OK 73113 or fax documents to BCRC 405 869 3309 For more information please visit http go cms gov cobro or call 1 855 798 2627 TTY TDD for the hearing or speech impaired 1 855 797 2627 Sincerely BCRC Enclosure BCRC Brochure CC 00017 RCLCP1 5 Learn about your letter at www msprc info TLL II 2 08 25 2010 SINGLP GEORGE HOLLOWELL PO BOX 1407 GREENVILLE MS 38702 1407 Name of Beneficiary HIC Date of Injury Illness Incident Dear Please note that if we know that you have an attorney or other individual representing you in this matter we are sending him her a copy of this letter If you have an attorney or other representative for this matter and his her name is not shown as a cc at the end of this letter indicating that he she is receiving a copy please contact us immediately If you have any questions regarding this letter and are represented by an attorney or other person in this matter you may wish to talk to your representative before contacting us This letter follows a previous letter notifying you your att
13. Box 138832 Oklahoma City OK 73113 MELOTANGHP 00044 CUMS geria CENTERS FOR amp MEDICAID SERVICES Benefits and Recovery Sincerely BCRC Case Analyst Enclosure Payment Summary Form NGHP P O Box 138832 Oklahoma City OK 73113 MLO74NGHP Page 2 of 2 00045
14. Center BCRC CONTACTS Benefits Coordination amp Recovery Center BCRC BCRC Customer Service Representatives are available to assist you Monday through Friday from 8 00 a m to 8 00 p m Eastern Time except holidays at toll free lines 1 855 798 2627 and TTY TDD 1 855 797 2627 for the hearing and speech impaired Non Group Health Plan NGHP Inquiries and Checks NGHP P O Box 138832 Oklahoma City OK 73113 Self Calculated Conditional Payment Amount Option and Fixed Percentage Option Self Calculated Conditional Payment Amount Fixed Percentage Option P O Box 138880 Oklahoma City OK 73113 Fax 1 405 869 3309 00001 To increase efficiency when sending a check or correspondence to the BCRC you may include a NGHP Correspondence Cover Sheet See Form A The NGHP Correspondence Cover Sheet is available in the Downloads section of the Non Group Health Plan Recovery page Please mail MSP General Correspondence e g information relative to Coordination of Benefits to Medicare MSP General Correspondence P O Box 138897 Oklahoma City OK 73113 8897 Fax 1 405 869 3307 ADDITIONAL CONTACT INFORMATION Contact 1 800 MEDICARE 1 800 633 4227 to Obtain general Medicare information Obtain information about Medicare Health Plan Choices Order Medicare publications Contact the My Medicare gov help desk 1 877 607 9663 for Assistance with MyMedicare gov Contact Social Security Ad
15. Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith 707 09 Chronic Ulcer Unsp 780 09 Alterat of Consciousness 780 79 Other Malaise Fatigue 780 80 Generalized Hyperhidrosis 780 09 Alterat of Consciousness 780 79 Other Malaise Fatigue 780 80 Generalized Hyperhidrosis 276 51 Dehydration 294 80 Mental D O Nos 345 90 Epilepsy Unsp 427 00 Paroxysmal SVT 294 80 Mental D O Nos 276 51 Dehydration 345 90 Epilepsy Unsp 427 00 Paroxysmal SVT 276 51 Dehydration V10 3 Mali Neop to Breast Per Hx 272 40 Hyperlipidemia Unsp 401 90 HTN Unsp 599 00 UTI 276 51 Dehydration V10 3 Mali Neop to Breast Per Hx 272 40 Hyperlipidemia Unsp 401 90 HTN Unsp 599 00 UTI 276 51 Dehydration V10 3 Mali Neop to Breast Per Hx 272 40 Hyperlipidemia Unsp 401 90 HTN Unsp 599 00 UTI 276 51 Dehydration V10 3 Mali Neop to Breast Per Hx 272 40 Hyperlipidemia Unsp 401 90 HTN Unsp 599 00 UTI 276 51 Dehydration V10 3 Mali Neop to Breast Per Hx 272 40 Hyperlipidemia Unsp 142 63 1 66 7 81 26 31 26 31 5 41 5 41 5 41 5 41 5 41 5 41 14 11 90 33 90 33 90 33 5 13 5 13 5 13 1 66 1 66 1 66 7 81 7 81 7 81 26 31 26 31 26 31 5 41 5 41 5 41 5 41 5 41 5 41 5 41 5 41 5 41 14 11 14 11 3 7
16. of that so that we are able to close your MSP case 00016 What Information Can You Expect From Us and When Medicare s Conditional Payment Amount Our system will automatically send you a Conditional Payment Letter within 65 days of the date on this letter It includes a Payment Summary Form which lists medical items and services Medicare has paid for that we believe are related to your claim Keep in mind that this list is not final or complete until your insurance or workers compensation claim is resolved If you would like the most up to date claims information please visit www MyMedicare gov Once your letter is issued you will be able to access conditional payment amount information through the MyMSP tab as well as current claims information using the MyMedicare gov blue button How to Elect a Simple Fixed Percentage Option For Repayment If You Have Experienced a Physical Trauma Based Injury If you experienced a physical trauma based injury and you get a liability insurance settlement judgment award or other payment of 5 000 or less Medicare offers the option to pay 25 of your gross settlement judgment award or other payment instead of the amount that Medicare would otherwise calculate If you wish to choose this option you must formally elect it at the same time that you send us information on your settlement judgment award or other payment Please visit the Beneficiary or Attorney Toolkit sections of the
17. you have sixty 60 days to request a judicial review by a Federal District Court The NOTICE OF DECISION OF MEDICARE APPEALS COUNCIL will set out your right to court review and the procedure to follow to file your case in the Federal District Court The minimum jurisdictional amount for 2013 2014 is 1 400 00 I have successfully filed an Appeal in the United States District Court for the Northern District of Mississippi Greenville Division in the case of Mattie Young As Administratrix Of The Estate Of Mattie Sue Delaney v Secretary Of Health And Human Services CIVIL ACTION NO 4 11CV002 B A in which the Court reversed and remanded the final decision of the Secretary of Health and Human Services The Court found that both the ALJ and Medicare Appeals Council mis stated the law and that Medicare bear s the ultimate burden of justifying the amounts it seeks in reimbursement Urso v Thompson 309 F Supp 2d 253 D Conn 2004 The court explained that recipients of Medicare benefits are perhaps in a better position as an initial matter to evaluate the reimbursement claim and to assess whether a payment made by Medicare was truly for an item or service that was untimely paid by the primary plan But even if a Medicare recipient had the initial burden of making a prima facie case that Medicare s reimbursement requests were overinclusive it is the Secretary who should bear the ultimate burden of persuasion on this issue
18. 09 30 2006 57 93 42 42 42 42 6 5939 OZUA EDWIN I 7806 2859 48 09 15 2006 09 30 2006 164 70 120 64 120 64 6 5939 OZUA EDWIN I 7806 2859 48 09 15 2006 09 30 2006 57 93 42 42 42 42 6 5939 i OZUA EDWIN I 7806 2859 48 09 15 2006 09 30 2006 164 70 120 64 120 64 6 5939 OZUA EDWIN I 7806 2859 48 09 15 2006 09 30 2006 289 65 212 12 212 12 500206290220360 512 KA GK REPORT NUMBER CONTRACTOR MEDICARE SECONDARY PAYER RECOVERY CONTRACTOR BENEFICIARY NAME BENEFICIARY HICN TOS 71 71 71 71 71 71 71 71 71 71 71 71 71 71 71 74 71 71 71 71 ICN 500206268399520 500206268399520 500206268399520 500206278255140 500206278255140 500206278255140 500206278255 140 500206278255140 500206278255140 500206278255 140 500206278255 140 500206285 152040 500206285 152080 500206290026970 50020633 1594330 50020633 1594330 50020633 1594330 500206283229980 500206285057 190 500206285057 190 LINE WH sok PROCESSING CONTRACTOR 512 512 512 512 512 512 512 512 512 512 512 512 512 512 512 512 512 512 512 512 PROVIDER NAME WEINER ROGER D WEINER ROGER D WEINER ROGER D MUNIR AMAN U MUNIR AMAN U MUNIR AMAN U MUNIR AMAN U MUNIR AMAN U MUNIR AMAN U MUNIR AMAN U MUNIR AMAN U WASEF MAHA MALICK SUSAN D BURKE PAT S OZUA EDWIN I OZUA EDWIN I OZUA EDWIN I MUNIR AMAN U MED EXPRESS OF MISSISSPPI
19. 2 PAFFORD MEDICAL 2948 V4984 7 04 21 2010 04 21 2010 24 00 16 18 16 18 SERVICES 0709 t SUM DF TOTAL CHARGES 208 053 85 TOTAL CONDITIONAL PAYMENT 38 850 99 PROVIDER NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr GreenBough Nsg Home GreenBough Nsg Home Greenbough Nsg Home Greenbough Nsg Home NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr NW MS Reg Med Ctr James E Warrington James E Warrington James E Warrington James E Warrington James E Warrington James E Warrington James E Warrington Michael R Whitmore Michael R Whitmore Lucy May CPL Related Unrelated Work Sheet CODES 513 00 Abscess of Lung 285 90 Anemia Unsp 345 90 Epilepsy Unsp 401 90 HTN Unsp 482 10 Pseudo Pneumonia 707 00 Decub Ulcer V72 6 Lab Examination V72 6 Lab Examination 707 00 Decub Ulcer 276 51 Dehydration V10 3 Pers Hx Malig Neo Breast 294 80 Mental D O Nos 401 90 HTN Unsp 414 00 Coron Atherosclerosis 718 44 Contx Hand Joint 716 99 Arthropathy To Multi Sites 718 44 Contx Hand J
20. 438 00 Cognitive Deficits V49 89 Spec Con Infl Hith Status 718 45 Contx Joint Pelvic Thigh 780 02 Transient Alt of Awareness 414 00 Coronary Atherosclerosis 719 40 Pain in Joint Unsp 276 51 Dehydration 599 00 UTI V72 81 Pre op Cardiovas Exam 38 90 Septicemia Unsp 599 00 UTI 276 51 Dehydration 599 00 UTI 276 51 Dehydration 599 00 UTI 276 51 Dehydration 599 00 UTI 21 21 15 77 15 77 15 77 15 77 21 21 21 21 19 43 19 43 13 41 13 41 12 95 12 95 58 06 58 06 2 30 59 85 59 85 90 69 90 69 38 87 38 87 21 21 15 77 15 77 15 77 15 77 3 45 3 45 21 21 21 21 19 43 19 43 13 41 13 41 33 74 33 74 33 74 33 74 34 84 34 84 34 84 34 84 30 07 30 07 2 30 2 30 9 21 2006 9 21 2006 9 22 2006 9 22 2006 9 22 2006 9 22 2006 9 22 2006 9 22 2006 9 22 2006 22 Sep 9 22 2006 22 Sep 10 1 2006 10 1 2006 10 1 2006 10 1 2006 10 1 2006 10 1 2006 10 1 2006 10 1 2006 10 1 2006 10 1 2006 10 1 2006 10 1 2006 10 4 2006 10 4 2006 10 6 2006 6 Oct 10 6 2006 10 6 2006 10 6 2006 10 6 2006 10 6 2006 10 6 2006 10 16 2006 10 16 2006 10 23 2006 10 23 2006 10 23 2006 10 23 2006 10 23 2006 10 24 2006 10 24 2006 10 24 2006 10 24 2006 10 24 2006 10 24 2006 00031 42 42 63 10 63 10 6 90 84 85 77 74 53 64 25 91 134 96 139 38 60 14 116 12
21. 5 24 2006 6 13 2006 7 19 2006 8 11 2006 8 11 2006 AMOUNT 10 145 80 33 88 55 73 5 923 68 816 76 1 245 49 3 193 92 3 333 27 6 266 86 60 14 60 14 60 14 60 14 60 14 60 14 60 14 25 71 00029 James E Warrington 719 40 Pain in Joint Unsp 60 14 8 23 2006 60 14 Edwin Ozua 780 60 Fever 29 92 9 15 2006 119 70 Edwin Ozua 285 90 Anemia Unsp 29 92 9 15 2006 Edwin Ozua 486 00 Pneumonia 29 92 9 15 2006 Edwin I Ozua 593 90 Kidney Ureter D O Unsp 29 92 9 15 2006 Edwin Ozua 780 60 Fever 15 08 9 15 2006 60 32 Edwin Ozua 285 90 Anemia Unsp 15 08 9 15 2006 Edwin Ozua 486 00 Pneumonia 15 08 9 15 2006 Edwin I Ozua 593 90 Kidney Ureter D O Unsp 15 08 9 15 2006 Edwin Ozua 780 60 Fever 10 60 9 15 2006 42 42 Edwin I Ozua 285 90 Anemia Unsp 10 60 9 15 2006 Edwin I Ozua 486 00 Pneumonia 10 60 9 15 2006 Edwin Ozua 593 90 Kidney Ureter D O Unsp 10 60 9 15 2006 Edwin Ozua 780 60 Fever 30 16 9 15 2006 120 64 Edwin I Ozua 285 90 Anemia Unsp 30 16 9 15 2006 Edwin Ozua 486 00 Pneumonia 30 16 9 15 2006 Edwin I Ozua 593 90 Kidney Ureter D O Unsp 30 16 9 15 2006 Edwin Ozua 780 60 Fever 10 60 9 15 2006 42 42 Edwin Ozua 285 90 Anemia Unsp 10 60 9 15 2006 Edwin Ozua 486 00 Pneumonia 10 60 9 15 2006 Edwin Ozua 593 90 Kidney Ureter D O Unsp 10 60 9 15 2006 Edwin Ozua 780 60 Fever 30 16 9 15 2006 120 64 Edwin I Ozua 285 90 Anemia Unsp 30 16 9 15 2006 Edwin
22. 58221 Line 8 Line 2 minus Line 7 3 582 22 Medicare Reduction of Lien 3 582 22 TOTAL Medicare REDUCED Lien 3 582 22 00041 HOLLOWELL LAW FIRM ATTORNEY AT LAW 3655 HIGHWAY 82 EAST GREENVILLE MS 38703 662 378 3103 TELEPHONE 662 378 3420 FACSIMILE GEORGE F HOLLOWELL JR MAILING ADDRESS POST OFFICE DRAWER 1407 GREENVILLE MS 38702 1407 hollowelllawfirm com April 3 2014 Medicare Secondary Payer Recovery Contractor P O Box 138832 Oklahoma City OK 73113 RE Lucy May Medicare XXX XX XXXX Date s of Injury 09 14 06 to 11 17 06 To Whom It May Concern Please find enclosed a copy of the letter will mailed to you on February 15 2011 requesting to Amend the Dates of Injury to September 14 2006 through November 17 2006 The basis for the amendment of the Date of Injuries is the opinion of Plaintiffs Expert Dr Keith Miller which is enclosed In regards to the Conditional Payment Letter our office received concerning Ms Lucy May on May 10 2011 and on August 25 2010 we do not agree with those portions of the claims which are not related as listed on the Payment Summary Form s that were attached to the Conditional Payment Letter aforementioned I have enclosed all these documents again also Those portions which we do not agree with are in our Related Unrelated worksheet which is enclosed The Related Unrelated worksheet is a line by line list of claims from the Payme
23. 6 50 90 Pafford Med Service Pafford Med Service Pafford Med Service Pafford Med Service Jaiyeola O Adeleye Kenneth W Kellough Kenneth W Kellough Kenneth W Kellough Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith 707 06 Chronic Ulc of Skin Ankle 780 09 Alt of Consciousness 707 06 Chronic Ulc of Skin Ankle 780 09 Alt of Consciousness 707 06 Chronic Ulc of Skin Ankle 276 51 Dehydration 507 00 Pneu D T Inh Food Vomitus 780 60 Fever 787 01 Nausea and Vomiting 209 00 Senile Dementia Uncompli 401 90 HTN Unsp 486 00 Pneumonia 530 81 Esophageal Reflux 787 01 Nauseau and Vomiting 290 Senile Dementia Uncompli 401 9 HTN Unsp 486 Pneumonia 530 81 Esophageal Reflux 787 01 Nausea and Vomiting 290 Senile Dementia Uncompli 401 9 HTN Unsp 486 Pneumonia 530 81 Esophageal Reflux 787 01 Nausea and Vomiting 290 Senile Dementia Uncompli 401 9 HTN Unsp 486 Pneumonia 530 81 Esophageal Reflux 787 01 Nausea and Vomiting 290 Senile Dementia Uncompli 401 9 HTN Unsp 486 Pneumonia 530 81 Esophageal
24. 6 60 30 79 132 66 243 52 27 13 49 46 82 58 138 22 22 51 270 99 46 22 45 26 6 66 9 86 Jason R Williams Jason R Williams Jason R Williams Jason R Williams Jason R Williams Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Jason R Williams Jason R Williams Jason R Williams Jason R Williams Jason R Williams Jason R Williams Jason R Williams Jason R Williams Pafford Med Service 530 81 Esophageal Reflux 707 09 Chronic Ulcer Unsp 780 60 Fever 276 51 Dehydration 786 05 SOB 276 51 Dehydration V12 59 Per Hx Sudden Car Arrest 174 90 Mali Neop of Breast 401 90 HTN Unsp 599 00 UTI 276 51 Dehydration V12 59 Per Hx Sudden Car Arrest 174 90 Mali Neop of Breast 401 90 HTN Unsp 599 00 UTI 276 51 Dehydration V12 59 Per Hx Sudden Car Arrest 174 90 Mali Neop of Breast 401 90 HTN Unsp 599 00 UTI 276 51 Dehydration V12 59 Per Hx Sudden Car Arrest 174 90 Mali Neop of Breast 401 90 HTN Unsp 599 00 UTI 276 51 Dehydration V12 59 Per Hx Sudden Car Arrest 174 90 Mali Neop of Breast 401 90 HTN Unsp 599 00 UTI 530 81 Esoph
25. 6 90 119 70 181 38 77 74 Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Lab Corp of America Lab Corp of America Lab Corp of America 276 51 Dehydration 599 00 UTI 276 51 Dehydration 599 00 UTI 276 51 Dehydration 599 00 UTI 276 51 Dehydration 38 90 Septicemia Unsp 599 00 UTI 707 07 Chronic Ulcer of Skin Heel 276 51 Dehydration 38 90 Septicemia Unsp 26 90 Unsp Protein Cal Malnutrit 599 00 UTI 414 00 Coronary Atherosclerosis 38 90 Septicemia Unsp 599 00 UTI 414 00 Coronary Atherosclerosis 38 90 Septicemia Unsp 599 00 UTI 414 00 Coronary Athersclerosis 38 90 Septicemia Unsp 599 00 UTI 718 45 Contx Joint of Pelvic Thigh V49 89 Specified Con Infl Hith Stat 438 21 Hemiplegia to Domin Side 707 00 Chronic Ulcer to Skin Unsp 718 45 Contx Joint Pelvic Thigh V49 89 Spec Con Infl Hlth Status 438 21 Hemiplegia to Domin Side 707 00 Chronic Ulcer to Skin Unsp 707 90 Chronic Ulcer Unsp 707 90 Chronic Ulcer Unsp 707
26. 7 3 58 3 58 3 58 2 71 2 71 2 71 5 68 5 68 5 68 0 75 0 75 0 75 9 16 9 16 9 16 4 27 2007 4 27 2007 4 27 2007 4 27 2007 4 27 2007 4 27 2007 4 27 2007 4 27 2007 4 27 2007 4 27 2007 4 27 2007 4 27 2007 4 27 2007 4 27 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 00033 221 16 15 01 138 22 7 50 11 89 14 32 10 86 22 73 3 00 36 66 Jason R Williams Jason R Williams Jason R Williams Jason R Williams Jason R Williams Jason R Williams Jason R Williams Jason R Williams Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith James W Major Jr Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Pafford Med Service Pafford Med Service Pafford Med Service Pafford Med Service Kenneth W Kellough Jason R Williams Jason R Williams Jason R Williams Jason R Williams Jason R Williams 276 51 Dehydration 294 80 Mental D O Nos 530 81 Esophageal Reflux 707 06 Chron Ulc to Skin Ankle 294 80 Mental D O Nos
27. 73 25 45 26 45 26 TH W 71 500208128209970 1 512 WILLIAMS JASON 27651 53081 03 02 2008 03 02 2008 38 00 6 66 6 66 70709 7806 71 500208128203990 1 512 WILLIAMS JASON 53081 27651 03 03 2008 03 03 2008 148 00 9 86 9 86 R 70709 7806 71 500208128204000 1 512 WILLIAMS JASON 27651 78605 03 03 2008 03 03 2008 38 00 6 66 6 66 R 71 500208259373560 1 512 SMITH ANDREA L 27651 V1259 03 03 2008 03 07 2008 254 00 131 58 131 58 1749 4019 59 90 71 500208259373560 2 512 SMITH ANDREA L 27651 V1259 03 03 2008 03 07 2008 59 00 27 05 27 05 1749 4019 59 90 71 500208259373560 3 512 SMITH ANDREA L 27651 V1259 03 03 2008 03 07 2008 59 00 27 05 27 05 Payment Summary Form DATE 08 25 CASE ID 2010 00025 CASE TYPE LIABILITY DATE OF INCIDEN T 01 01 2006 TOUT REPORT NUMBER CONTRACTOR MEDICARE SECONDARY PAYER RECOVERY CONTRACTOR BENEFICIARY NAME BENEFICIARY HICN MM a i DIAGNOSIS ICD TOS 71 71 71 71 71 71 71 71 wA 71 71 71 ICN 500208259373560 500208259373560 500208128203980 500208 128203980 50020807402 1530 50020807402 1530 500208 105132390 500208 105132390 500208 128204010 500208 128204010 500208259373550 500208258373550 LINE PROGESSING CONTRACTOR 512 512 512 512 512
28. 8 185400 500208249 111450 LINE PROCESSING CONTRACTOR 740 512 512 512 512 512 512 512 512 512 512 512 512 512 PROVIDER NAME ORATION OF AM LABORATORY CORP ORATION OF AM MED EXPRESS DF MISSISSPPI MED EXPRESS OF MISSISSPPI MED EXPRESS OF MISSISSPPI MED EXPRESS OF MISSISSPPI PROFESSIONAL CL INICAL LAB PROFESSIONAL INICAL LAB PROFESSIONAL CL INICAL LAB PROFESSIONAL CL INICAL LAB PROFESSIONAL INICAL LAB PROFESSIONAL INICAL LAB WILLIAMS R WILLIAMS R SMITH ANDREA L CL cL GL JASON JASON DIAGNOSIS ICD 7079 53640 71845 78009 53640 71845 78009 4380 43821 7 1843 71845 4380 43821 7 1843 71845 2724 4019 70 79 78099 4019 2724 70 79 78099 78099 2724 4 019 7079 78099 2724 4 019 7079 78099 2724 4 019 7079 78099 2724 4 019 7079 27651 2948 5 3081 70706 2948 27651 5 308 1 70706 27651 7806 Payment Summary Form FROM DATE 01 22 2007 04 27 2007 04 27 2007 04 27 2007 04 27 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 12 11 2007 12 11 2007 12 11 2007 TO DATE 01 22 2007 04 27 2007 04 27 2007 04 27 2007 04 27 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 10 22 2007 12 11 2007 12 11 2007 12 18 2007 CASE I TOTAL CHARGES 34 95 395 00 19 00 395 00 9 50 50 00 60 25 30 00 60 00 16 50 39 00 38 00 215 00 199 00 i t Q e j e DATE 08 25 2010 D CAS
29. 90 Chronic Ulcer Unsp 25 91 25 91 142 51 142 51 26 82 26 82 1 78 1 78 1 78 1 78 1 78 1 78 1 03 5 18 12 48 33 74 3 66 12 03 28 89 9 77 1 78 1 78 1 03 1 03 5 18 5 18 12 48 12 48 33 74 33 74 33 74 3 66 3 66 3 66 10 24 2006 10 24 2006 10 24 2006 10 24 2006 10 24 2006 10 24 2006 10 24 2006 10 24 2006 10 24 2006 10 24 2006 10 25 2006 10 25 2006 10 25 2006 10 25 2006 11 14 2006 11 14 2006 11 14 2006 11 14 2006 11 14 2006 11 14 2006 11 14 2006 11 14 2006 11 14 2006 11 17 2006 11 17 2006 11 17 2006 11 17 2006 11 17 2006 11 17 2006 11 17 2006 11 17 2006 1 22 2007 1 22 2007 1 22 2007 51 82 285 03 53 64 7 15 7 15 3 10 15 55 37 46 134 96 14 67 12 03 28 89 9 77 Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Professional Clin Lab Professional Clin Lab Professional Clin Lab Professional Clin Lab Professional Clin Lab Professional Clin Lab Professional Clin Lab Professional Clin Lab Professional Clin Lab Professional Clin Lab Professional Clin Lab Professional Clin Lab Professional Clin Lab Professiona
30. E TYPE LIABILITY DATE OF INCIDENT 01 01 2006 REIMBURSED CONDITIONAL AMOUNT PAYMENT 9 77 221 16 221 16 15 01 15 01 138 22 138 22 ES 7 50 11 89 11 89 14 32 14 32 10 86 10 86 22 73 22 73 3 00 3 00 al 36 66 36 66 6 60 86 60 30 79 30 79 132 66 132 66 REPORT NUMBER CONTRACTOR MEDICARE SECONDARY PAYER RECOVERY CONTRACTOR BENEFICIARY NAME BENEFICIARY HICN TOS ICN LINE PROCESSING PROVIDER DIAGNOSIS ICD FROM TO TOTAL REIMBURSED CONDITIONAL CONTRACTOR NAME DATE DATE CHARGES AMOUNT PAYMENT UU ES E aaa 71 500208248111450 2 512 SMITH ANDREA 27651 7806 12 14 2007 12 18 2007 375 00 243 52 243 52 71 500208249111450 3 512 SMITH ANDREA L 27651 7806 12 11 2007 12 18 2007 59 00 27 13 27 13 71 500208249111450 4 512 SMITH ANDREA L 27651 7806 12 11 2007 12 18 2007 100 00 49 46 49 46 71 500207362212860 1 512 MAJOR JR JAMES 70713 12 17 2007 12 17 2007 243 00 58 82 58 w 71 500207355133020 1 512 MED EXPRESS OF 70703 2903 3 12 18 2007 12 18 2007 395 00 1 22 5138 22 MISSISSPPI 3521 71845 71 500207355133020 2 512 MED EXPRESS OF 70703 2903 3 12 18 2007 12 18 2007 35 55 51 22 51 MISSISSPPI 3521 71845 71 500208074021060 1 512 PAFFORD MEDICAL 78079 7806 03 02 2008 03 02 2008 740 00 99 270 99 SERVICES 71 500208074021060 2 512 PAFFORD MEDICAL 78079 7806 03 02 2008 03 02 2008 66 00 22 46 22 SERVICES 71 500208119123500 1 512 KELLOUGH KENNE 27651 03 02 2008 03 02 2008 1
31. II III INDEX The Step by Step Guide on Medicare Set Aside s The Medicare Secondary Payer Recovery Portal MSPRP Forms A NGHP Correspondence Cover Sheet B Client Information Worksheet C Proof of Representation D Rights amp Responsibilities Letter E CPL Demand Letter Payment Summary Form G CPL Related Unrelated Work Sheet H Final Settlement Detail Document I Procurement Cost Worksheet J Beneficiaries CPL Dispute Letter K BCRC Final Demand before Procurement Cost 01 08 09 10 45 10 11 13 14 15 17 18 19 20 28 29 39 40 41 42 43 44 45 THE STEP BY STEP GUIDE ON MEDICARE SET ASIDE S AND HOW TO APPEAL AND OR DISPUTE A LIEN AMOUNT By George Boo Hollowell The Centers for Medicare amp Medicaid Services CMS has completed the restructuring of the Coordination of Benefits COB and Medicare Secondary Payer MSP recovery activities and this website www msprcinfo com is no longer accessible Information that was previously obtained from this site is now located on CMS gov and can be accessed via the following links Coordination of Benefits amp Recovery Overview http go cms gov cobro Attorney Services http go cms gov attorney Beneficiary Services http go cms gov bene Insurer Services http go cms gov insurer The new entitiy that coordinates the Medicare recovery activities is the Benefits Coordination amp Recovery
32. ISSISSIPPI 5130 2859 34 09 14 2006 10 06 2006 97 973 97 10 145 80 10 145 80 02 REGIONAL MED 590 4019 482 NTER 1 40 20724202598802 52280 NW MISSISSIPPI 70700 726 05 01 2007 05 01 2007 554 24 33 88 33 88 02 REGIONAL MED CE NTER 40 20721804411702 52280 NW MISSISSIPPI 70700 V726 07 05 2007 07 05 2007 886 82 55 73 55 73 02 REGIONAL MED CE NTER 60 20736004689202 0 52280 MISSISSIPPI 27651 103 2 12 11 2007 12 18 2007 17 708 41 5 923 68 5 923 68 02 REGIONAL MED 948 4019 414 NTER 00 40 20825400615702 o 230 GREENBOUGH NURS 71844 71699 08 15 2008 08 29 2008 2 041 98 816 76 816 76 ING CENTER 40 20828101591002 0 230 GREENBOUGH NURS 71844 71699 09 01 2008 09 26 2008 3 113 70 1 248 49 1 245 49 ING CENTER 60 20835803336602 52280 NW MISSISSIPPI 4660 103 29 12 17 2008 12 18 2008 7 194 55 3 193 92 3 193 92 02 REGIONAL MED CE 48 34590 401 NTER 9 60 20934102141502NT 0 52280 NW MISSISSIPPI 72981 25000 11 26 2009 11 27 2009 10 643 78 3 333 27 3 339 27 A 02 REGIONAL MED CE 2724 27651 3 NTER 4590 60 21011702081602 0 52280 NW MISSISSIPPI 5070 103 27 04 14 2010 04 21 2010 47 182 38 6 266 86 6 266 86 02 REGIONAL MED CE 24 2948 4019 NTER 71 500206039063170 1 512 WARRINGTON JAM 78650 01 20 2006 01 20 2006 85 00 60 14 60 14 ES E 71 500206047 180020 1 512 WARRINGTON JAM 71940 02 15 2006 02 15 2006 85 00 60 14 60 14
33. Maha Wasef Susan D Malick Susan D Malick Susan D Malick Susan D Malick Pat S Burke Pat S Burke Edwin Ozua Edwin Ozua Edwin Ozua Edwin Ozua Edwin Ozua Edwin Ozua Edwin Ozua Edwin Ozua Edwin Ozua Edwin Ozua Edwin Ozua Edwin Ozua Aman U Munir Aman U Munir Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss Med Express of Miss James E Warrington James E Warrington Tarence Wade Tarence Wade Gus D Berryhill Jr Gus D Berryhill Jr Gus D Berryhill Jr Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith 518 30 Pulmonary Eosinophilia 485 00 Bronchopneumonia Unsp 513 00 Abscess of Lung 401 90 HTN Unsp 482 10 Pseudomonas Pneumonia 707 05 Chronic Ulcer of Skin Butt 513 00 Abscess of Lung 401 90 HTN Unsp 482 10 Pseudomonas Pneumonia 707 05 Chronic Ulcer of Skin Butt 401 90 HTN Unsp 513 00 Abscess of Lung 780 60 Fever 285 90 Anemia Unsp 486 00 Pneumonia 593 90 Kidney Ureter D O Unsp 780 60 Fever 285 90 Anemia Unsp 486 00 Pneumonia 593 90 Kidney Ureter D O Unsp 780 60 Fever 285 90 Anemia Unsp 486 00 Pneumonia 593 90 Kidney Ureter D O Unsp 485 00 Bronchopneumonia Unsp 486 00 Pneumonia 438 00 Cognitive Deficits V49 89 Spec Cond Infl Status 718 45 Contx Joint amp Pelvic Thigh 780 02 Transient Alt of Awareness
34. Ozua 486 00 Pneumonia 30 16 9 15 2006 Edwin Ozua 593 90 Kidney Ureter D O Unsp 30 16 9 15 2006 Edwin I Ozua 780 60 Fever 53 08 9 15 2006 212 12 Edwin I Ozua 285 90 Anemia Unsp 53 03 9 15 2006 Edwin Ozua 486 00 Pneumonia 53 03 9 15 2006 Edwin Ozua 593 90 Kidney Ureter D O Unsp 53 03 9 15 2006 Roger D Weiner 785 20 Undx Cardiac Murmur 37 46 9 18 2006 37 46 Roger D Weiner 785 20 Undx Cardiac Murmur 15 55 9 18 2006 15 55 Roger D Weiner 785 20 Undx Cardiac Murmur 3 10 9 18 2006 3 10 Aman U Munir 518 30 Pulmonary Eosinophilia 0 00 0 00 9 21 2006 0 00 Aman U Munir 485 00 Bronchopneumonia Unsp 0 00 0 00 9 21 2006 Aman U Munir 518 30 Pulmonary Eosinophilia 12 95 9 21 2006 25 91 Aman U Munir 485 00 Bronchopneumonia Unsp 12 95 9 21 2006 Aman U Munir 518 30 Pulmonary Eosinophilia 0 00 0 00 9 21 2006 0 00 Aman U Munir 485 00 Bronchopneumonia Unsp 0 00 0 00 9 21 2006 Aman U Munir 518 30 Pulmonary Eosinophilia 58 43 9 21 2006 116 87 Aman U Munir 485 00 Bronchopneumonia Unsp 58 43 9 21 2006 Aman U Munir 518 30 Pulmonary Eosinophilia 0 84 9 21 2006 1 69 Aman U Munir 485 00 Bronchopneumonia Unsp 0 84 9 21 2006 Aman U Munir 518 30 Pulmonary Eosinophilia 21 21 9 21 2006 42 42 Aman U Munir 485 00 Bronchopneumonia Unsp 21 21 9 21 2006 Aman U Munir 518 30 Pulmonary Eosinophilia 25 91 9 21 2006 51 82 Aman U Munir 485 00 Bronchopneumonia Unsp 25 91 9 21 2006 00030 Aman U Munir Aman U Munir Maha Wasef Maha Wasef Maha Wasef
35. PRP Application Link found in the Related Links section However registration must occur before access to the MSPRP is permitted MSPRP User Manual The MSPRP User Manual was written to help you understand how to use the MSPRP The User Manual is available under the Reference Material menu option of the MSPRP application Assistance with MSPRP Issues For problems related to registration and other technical issues please contact the Benefits Coordination amp Recovery Center BCRC EDI Department at 1 646 458 6740 For questions related to a case or why an MSPRP option is unavailable 1 grayed out please contact the Benefits Coordination amp Recovery Center BCRC at 1 855 798 2627 00009 CMS COB we Coordination of CENTERS FOR MEDICARE amp MEDICAL SERVICES Benefits and Recovery NGHP Correspondence Cover Sheet Beneficiary s Name HIC Date of Incident Case ID can be found on Rights and Responsibilities letter This cover sheet is for your use when mailing or faxing in correspondence to the Benefits Coordination amp Recovery Center BCRC Please retain a COPY of this cover sheet for any future correspondence The information above will ensure accuracy when handling your case documentation Please indicate the type of correspondence you are submittirig to the BCRC to facilitate routing Check all that apply O Check O Settlement information O Retainer agreement or other authorization documentat
36. Reflux 787 01 Nausea and Vomiting 290 Senile Dementia Uncompli 486 Pneumonia 401 9 HTN Unsp 530 81 Esophageal Reflux 77 55 8 33 28 04 42 69 28 22 5 67 5 67 5 67 5 67 5 67 77 55 8 33 42 69 42 69 28 22 28 22 28 22 28 22 5 67 5 67 5 67 5 67 5 67 5 67 5 67 5 67 5 67 5 67 5 67 5 67 5 67 5 67 5 67 5 67 5 67 5 67 5 67 5 67 11 27 2009 11 27 2009 11 27 2009 11 27 2009 3 11 2010 4 13 2010 4 13 2010 4 13 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 00038 155 10 16 66 28 04 128 08 141 11 28 38 28 38 28 38 28 38 28 38 Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Pafford Med Service Pafford Med Service Pafford Med Service Pafford Med Service Pafford Med Service Pafford Med Service TOTALS 787 01 Nausea and Vomiting 290 Senile Dementia Uncompli 401 9 HTN Unsp 486 Pneumonia 530 81 Esophageal Reflux 787 01 Nausea and Vomiting 290 Senile Dementia Uncompli 401 9 HTN Unsp 486 Pneumon
37. ageal Reflux 276 51 Dehydration 780 60 Fever 780 97 Altered Mental Status 780 97 Altered Mental Status 276 51 Dehydration 530 81 Esophageal Reflux 780 60 Fever 707 09 Chronic Ulcer Unsp 2 46 3 33 26 31 26 31 5 41 5 41 5 41 5 41 5 41 5 41 14 11 14 11 2 46 7 81 142 63 2 46 2 46 3 33 26 31 26 31 26 31 5 41 5 41 5 41 5 41 5 41 5 41 5 41 5 41 5 41 14 11 14 11 14 11 2 46 2 46 2 46 7 81 7 81 7 81 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 3 2008 3 6 2008 3 6 2008 3 6 2008 3 6 2008 3 6 2008 3 6 2008 3 6 2008 3 6 2008 6 66 131 58 27 05 27 05 27 05 70 57 9 86 31 26 3 7 200860025 9142 63 Pafford Med Service Pafford Med Service Pafford Med Service Pafford Med Service Pafford Med Service Pafford Med Service Pafford Med Service Jason R Williams Jason R Williams Jason R Williams Jason R Williams Jason R Williams Jason R Williams Jason R Williams Jason R Williams Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L Smith Andrea L
38. amount is not a final listing and will need to be updated once we receive final settlement information from you It would be in your best interest to keep Medicare s payments and the statutory obligation to satisfy Medicare in mind when the final dollar amount is negotiated and accepted in resolution of the claim with the third party If the case has settled please furnish our office with a copy of 1 The settlement agreement from the third party payer showing the total amount of the settlement signed and dated AND 2 Your closing statement reflecting the actual amount of the attorney s fees and costs excluding medical bills Thank you for your assistance and cooperation in this matter If you have any questions regarding this matter please contact us at 1 866 677 7220 TTY TDD 1 866 677 7294 for the hearing and speech impaired Sincerely Medicare Secondary Payer Recovery Contractor PO BOX 33828 DETROIT MI 48232 5828 Enclosures Payment Summary Form cc GEORGE HOLLOWELL RCLCP2 00019 Payment Summary Form e CN Q Q e DATE 08 25 2010 REPORT NUMBER CONTRACTOR MEDICARE SECONDARY PAYER RECOVERY CONTRACTOR CASE ID CASE TYPE LIABILIT DATE OF INCIDENT BENEFICIARY NAME BENEFICIARY HICN TOS ICN LINE PROCESSING PROVIDER DIAGNOSIS ICD FROM TO TOTAL REIMBURSED CONDITIONAL CONTRACTOR NAME DATE DATE CHARGES AMOUNT PAYMENT 60 20628403336402 52280 NW M
39. and or wrongful death claim 2 You must file either Proof of Representation or Consent to Release with the BCRC If you want to represent a beneficiary communicate with and provide information to BCRC then you must file a Proof of Representation However if you only want information such as conditional payment information but you are not representing the beneficiary then file a Consent to Release My suggestion is to always file the Proof of Representation Form CAVEAT Must write client name and HICN at the right hand top corner of each and every page you send to BCRC or they will NOT accept 3 The BCRC representative will inform all parties associated with your client s case that they shall receive a Rights And Responsibilities RAR letter See Form D if the Proof of Representation or Consent to Release is submitted 4 If you do not receive the Rights And Responsibilities RAR letter within three 3 weeks of contacting the BCRC call the BCRC at 1 855 798 2627 Follow the prompts until a representative is on the line Inform the BCRC representative you have NOT received the Rights And Responsibilities RAR letter and that you have spoken with a specific BCRC representative at a certain date and time documented on your Client Information Worksheet The representative will instruct you as to what must be done to receive this letter If the BCRC needs additional information and or doc
40. by the Procurement Cost See Form T You should receive a Final Demand Letter from BCRC usually within thirty 30 to sixty 60 days You must send a check on or before the date set out in the Final Demand Letter or interest will be charged from the date set out in the Final Demand Letter Procurement Costs are set out in accordance with 42C F R Part 411 37 as in the following EXAMPLE EXAMPLE Line 1 Amount of Settlement 135 000 00 Line 2 Medicare Payments 7 164 43 Line 3 Attorney s Fees 54 000 00 Line 4 Expenses 13 726 96 Line 5 Line 3 plus 4 67 726 96 Line 6 Line 5 divided by line 1 50 Line 7 Line 2 x line 6 3 582 21 Line 8 Line 2 minus line 7 3 582 22 Line 8 Based on this calculation the amount of your related claim is 3 582 22 This is your reduced Medicare lien amount Line 2 Medicare Payments of 7 164 43 is the final amount owed before Procurement Costs s are applied 00004 calculated LEVEL 1 LEVEL 2 LEVEL 3 If you dispute the amount demanded in the CPL send your Related Unrelated Worksheet s along with the same documents in 5 b above to the address set out in the CPL Also include all documents medical records depositions and opinions that will support your position as to what is unrelated You may want to use portions of the Defendant s expert opinions and or depositions to support your position but be careful You will receive a response within for
41. ia 530 81 Esophageal Reflux 294 8 Mental D O Nos V49 84 Bed Confinement 707 09 Chronic Ulcer to Skin Unsp 294 8 Mental D O Nos V49 84 Bed Confinement 707 09 Chronic Ulcer to Skin Unsp 5 67 10 02 50 19 5 39 7 164 43 5 67 5 67 5 67 5 67 10 02 10 02 10 02 10 02 50 19 50 19 5 39 5 39 31 771 54 4 14 2010 28 38 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 14 2010 50 14 4 14 2010 4 14 2010 4 14 2010 4 14 2010 4 21 2010 150 58 4 21 2010 4 21 2010 4 21 2010 16 18 4 21 2010 4 21 2010 38 850 99 00039 Benefits and Recovery L Cms Final Settlement Detail Document Beneficiary Name Medicare Number Date of Incident When a beneficiary receives a settlement judgment award or other payment Medicare is entitled to recover associated payments made by the Medicare program If certain conditions are met Medicare reduces its conditional payment to take into account a proportionate share of the costs incurred in resolving the beneficiary s claim See 42 C F R 411 37 In general the recovery demand must be against the individual or entity that received payment the costs must have been incurred because the matter was disputed and the costs must be paid by the individual or entity against whom which Medicare seeks recovery There is no proportionate reduction if payment is not in dispute for example a payment for no fault insurance In order for Medicare t
42. ion O Other Note A Conditional Payment Letter is sent automatically as soon as the information is available Separate requests for initial Conditional Payment Amounts will not make Conditional Payment information available sooner In order to accurately associate claims to your case please include a description of the injury i e Knee Physical Therapy Slip and Fall Lumbar Injury Submit correspondence to the BCRC address listed below Liability Insurance No Fault Insurance Workers Compensation NGHP PO Box 138832 Oklahoma City OK 73113 00010 Client Information WORKSHEET Client s Name and Information f Applicable Can be Name of Deceased Client CLIENT S NAME PHONE NUMBER Last Known Type of Claim Liability Insurance No Fault Insurance Workers Compensation Client s Last Known Address If Deceased last known address of deceased IF DECEASED Administrator Administratrix Name Address and Phone Number Client s Date of Birth Gender Date of Death Client s Medicare Number Date of Injurv Accident Illness ICD 9 Codes www ICD9data com 00011 BCRC MSPRP MSP Step 1 Step 6 Step 7 BCRC Benefits Coordination amp Recovery Center WORKSHEET Benefits Coordination amp Recovery Center Medicare Secondary Payer Recovery Portal Medicare Secondary Payer Call BCRC 1 855 798 2627 Date COBC Notified Representative s Name
43. l Clin Lab Professional Clin Lab Professional Clin Lab Professional Clin Lab Professional Clin Lab Professional Clin Lab Professional Clin Lab Professional Clin Lab Professional Clin Lab Professional Clin Lab Professional Clin Lab 536 40 Gastrostomy Comp Unsp 718 45 Contx Joint amp Pelvic Thigh 780 09 Alt of Consciousness 536 40 Gastrostomy Comp Unsp 718 45 Contx Joint Pelvic Thigh 780 09 Alt of Consciousness 438 00 Cognitive Deficits 438 21 Hemiplegia to Domin Side 718 43 Contx of Forearm Joint 718 45 Contx Joint amp Pelvic Thigh 438 00 Cognitive Deficits 438 21 Hemiplegia to Domin Side 718 43 Contx of Forearm Joint 718 45 Contx Joint amp Pelvic Thigh 272 40 Hyperlipidemia Unsp 401 90 HTN Unsp 707 90 Chronic Ulcer Unsp 780 99 Other General Sxs 401 90 HTN Unsp 272 40 Hyperlipidemia 707 90 Chronic Ulcer Unsp 780 99 Other General Sxs 780 99 Other General Sxs 272 40 Hyperlipidemia Un Unsp 401 90 HTN Unsp 707 90 Chronic Ulcer Unsp 780 99 Other General Sxs 272 40 Hyperlipidemia Unsp 401 90 HTN Unsp 707 90 Chronic Ulcer Unsp 780 99 Other General Sxs 272 40 Hyperlipidemia Unsp 401 90 HTN Unsp 707 90 Chronic Ulcer Unsp 780 99 Other General Sxs 272 40 Hyperlipidemia Unsp 401 90 HTN Unsp 707 90 Chronic Ulcer Unsp 2 97 3 58 2 71 5 68 0 75 9 16 73 72 73 72 73 72 5 00 5 00 5 00 34 55 34 55 34 55 34 55 1 87 1 87 1 87 1 87 2 97 2 97 2 9
44. lection action while your appeal or waiver of recovery request is being processed What Information We Need From You Do you have a lawyer or other person representing you Medicare works to protect your privacy We are not allowed to communicate with anyone other than you about your MSP case unless you tell us to do so If you have a lawyer or other person representing you please see the enclosed brochure It explains what type of information we need from you in order to work directly with your lawyer or representative Is the information we have on your claim correct If the information at the top of this letter is incorrect or if you filed a no fault insurance or workers compensation claim and do not see the insurer carrier listed as a cc at the end of this letter please contact the Benefits Coordination amp Recovery Center BCRC immediately at 1 855 798 2627 TTY TDD for the hearing or speech impaired 1 855 797 2627 Has your insurance or workers compensation claim already been resolved If you already got a settlement judgment award or other payment we need the following information o The date and total amount of your settlement judgment award or other payment o A list of the attorney fees and other costs that you had to pay in order to get your settlement judgment award or other payment If your insurance or workers compensation claim was dismissed or otherwise closed we need documentation
45. lti Sites 730 39 Periostitis Invol Multi Sites 730 39 Periostitis Invol Multi Sites 466 00 Acute Bronchitis 294 80 Mental D O Nos 345 90 Epilepsy Unsp 401 90 HTN Unsp 466 00 Acute Bronchitis 401 90 HTN Unsp 429 20 Cardiovascular Dz Unsp 401 90 HTN Unsp 276 51 Dehydration 1 72 345 90 Epilepsy Unsp 729 81 Swelling of Limb 729 81 Swelling of Limb 729 50 Pain in Limb 729 81 Swelling of Limb 729 50 Pain in Limb 276 51 Dehydration 132 01 729 81 Swelling In Limb 276 51 Dehydration 22 39 345 90 Epilepsy Unsp 401 90 HTN Unsp 785 00 Tachycardia Unsp 729 81 Swelling in Limb 276 51 Dehydration 10 18 345 90 Epilepsy Unsp 785 00 Tachycardia Unsp 14 11 47 54 5 13 18 52 3 00 17 28 1 66 1 66 1 66 1 66 2 11 2 11 2 11 1 72 1 72 1 72 147 34 147 34 8 33 8 33 22 39 22 39 22 39 22 39 10 18 10 18 10 18 3 27 2008 3 27 2008 3 31 2008 3 31 2008 3 31 2008 3 31 2008 3 31 2008 3 31 2008 9 25 2008 9 25 2008 9 25 2008 12 16 2008 12 16 2008 12 16 2008 12 16 2008 12 17 2008 12 17 2008 12 17 2008 11 26 2009 11 26 2009 11 26 2009 11 26 2009 11 26 2009 11 26 2009 11 26 2009 11 26 2009 11 26 2009 11 26 2009 11 26 2009 11 26 2009 11 26 2009 11 26 2009 11 26 2009 11 26 2009 11 26 2009 1 1 26 2008 5037 142 63 15 41 18 52 3 00 17 28 6 66 6 35 6 90 294 68 16 66 132 01 111 9
46. ministration 1 800 772 1213 to Enroll in the Medicare program Replace your Medicare card Change your address Verify Medicare coverage CMS gov A federal government website managed by the Centers for Medicare amp Medicaid Services 7500 Security Boulevard Baltimore MD 21244 00002 1 When you agree to accept a workers compensation personal injury and or Wrongful Death Client obtain the following information in order to protect your client and yourself from future liability for Medicare payment s made on behalf of your client CAVEAT Medicare has a 1 000 00 settlement amount threshold in order for Medicare to seek reimbursement a Clients name last known address and a phone number Deceased client if applicable b Type of Claim Liability Insurance No Fault Insurance or Workers Compensation Clients date of birth and gender Clients date of death if applicable Clients Health Insurance Claim Number HICN Medicare Number Date of injury accident illness A description of alleged injury accident illness In addition if you are familiar with ICD 9 codes include the ICD 9 code s with each injury accident illness for best results ICD 9 Code site we use www ICD9data com h Name and address of Workers Compensation carrier if applicable i Name address and phone number of Attorney Client will be the same whether for a workers compensation claim injury claim
47. nce or workers compensation claim 2 What information we need from you What information you can expect from us and when 4 How and when you are able to elect a simple fixed percentage option for repayment and 5 How to contact us 00015 What Happens When You Have Medicare and You file a Liability Insurance including Self Insurance No Fault Insurance or Workers Compensation Claim Applicable Medicare law says that liability insurance including self insurance no fault insurance and workers compensation must pay for medical items and services before Medicare pays This law can be found at 42 U S C Section 1395y b 2 A and B However Medicare makes conditional payments while your insurance or workers compensation claim is being processed to make sure you get the medical services you need when you need them If you get a n insurance or workers compensation settlement judgment award or other payment Medicare is entitled to be repaid for the items and services it paid for conditionally If you receive a settlement judgment award or other payment related to this claim and Medicare determines that it has made conditional payments that must be repaid you will get a demand letter The demand letter explains how Medicare calculated the amount it needs to be repaid and it also explains your appeal and waiver rights If you decide to appeal or request a waiver of recovery Medicare will not take any col
48. nformation and Signature Date Beneficiary s Name please print exactly as shown on your Medicare card Beneficiary s Health Insurance Claim Number number on your Medicare card Date of Illness Injury for which the beneficiary has filed a liability insurance no fault insurance or workers compensation claim Beneficiary Signature Date signed Representative Signature Date Representative s Signature Date signed 00014 Benefits and Reco EMS ern Goordination of CENTERS FOR MEDICARE amp MEDICAID SERVICES very Print Date Insert name Insert address 1 Insert address 2 Insert city state zip code SUBJECT Medicare Secondary Payer Rights and Responsibilities Letter for Beneficiary Name Medicare Number Case Identification Number Insurer Claim Number Insurer Policy Number Date of Incident Dear Addressee Name You are receiving this letter because we were notified that you filed a liability insurance including self insurance no fault insurance or workers compensation claim This is confirmation that a Medicare Secondary Payer MSP recovery case has been established in our system If we know that you have a lawyer or other person representing you we have sent him or her a courtesy copy of this letter and you will see him or her listed as a cc at the end of this letter This letter gives you information on the following 1 What happens when you have Medicare and file an insura
49. nt Summary Form s which we separated We then causally related Ms May s injuries from September 14 2006 through November 17 2006 to the injury date s we reported initially when we contacted COBC and reported the injury date s injuries and the ICD 9 Codes that were applicable The Total Conditional Payment listed on the final page of the Payment Summary Form is 38 850 99 We applied the Related Unrelated worksheet 00042 to our amended dates of September 14 2006 to November 17 2006 We causally relate 7 164 43 to the injuries we reported We reduced this amount by the procurement costs Therefore the total amount due Medicare prior to reducing for procurement cost s is 7 164 43 However the Procurement Cost is 3 582 21 which should be reduced from the 7 164 43 leaving a balance owed Medicare of 3 582 22 Please respond so we may resolve the amount due Very Truly Yours George F Hollowell Jr Enclosures Letter to MSPRC dated 2 15 11 Dr Keith Miller s Opinion Related Unrelated Worksheet CPL from MSPRC dated 8 25 11 and 5 10 2011 Payment Summary Form s Consent To Release Letters of Administration Authorization To Release 00043 Coordination of CENTERS FOR MEDICARE amp MEDICAID SERVICES Benefits and Recovery UMS pman April 26 2014 2027 1 SP 0 500 HOLLOWELL LAW FIRM 3601 HIGHWAY 82 EAST GREENVILLE MS 38702 hi Beneficiary Medica
50. o properly calculate the net refund it is due please supply the information outlined below This information will also be used to update the beneficiary s records to show resolution of this matter If you have a representative this information should be submitted by your representative on his her letterhead Total Amount of the Settlement Total Amount of Med Pay or PIP Attorney Fee Amount Paid by the Beneficiary Additional Procurement Expenses Paid by the Beneficiary Please submit an itemized listing of these expenses Date the Case Was Settled This information should be submitted along with a copy of this notice to Benefits Coordination amp Recovery Center NGHP Post Office Box 138832 Oklahoma City OK 73113 If you have any questions concerning this matter please call the Benefits Coordination amp Recovery Center BCRC at 1 855 798 2627 TTY TDD 1 855 797 2627 for the hearing and speech impaired or you may contact us in writing at the address above If you contact us in writing please be sure to include the beneficiary s name and his her Medicare health insurance claim number 00040 Procurement Cost Worksheet Medicare xxx xx xxxxA Lucy May April 3 2014 Line 1 Amount of Settlement 135 000 00 Line 2 Medicare Payments 7 164 43 Line 3 Attorney s Fees 40 54 000 00 Line 4 Expenses 13 726 96 Line 5 Line 3 plus Line 4 67 726 96 Line 6 Line 5 divided by 1 50 Line 7 Line 2 x Line 6 3
51. oint 716 99 Arthropathy to Multi Sites 466 00 Acute Bronchitis V10 3 Pers Hx Malig Neo Breast 294 80 Mental D O Nos 345 90 Epilepsy Unsp 401 90 HTN Unsp 729 81 Swelling of Limb 250 00 DM Type II 272 40 Hyperlipidemia Nos 276 51 Dehydration 345 90 Epilepsy Unsp 507 00 Pneu D T Inh food Vomitus V10 3 Pers Hx Malig Neo Breast 272 40 Hyperlipidemia Nos 294 80 Mental D O Nos 401 90 HTN Nos 786 50 Chest Pain Unsp 719 40 Pain in Joint Unsp 719 40 Pain in Joint Unsp 719 40 Pain in Joint Unsp 719 40 Pain in Joint 719 40 Pain in Joint Unsp 719 40 Pain in Joint Unsp 729 50 Pain in Limb 440 20 Atherosclerosis of Extremity RELATED UNRELATED 2 029 16 2 029 16 2 029 16 2 029 16 16 94 27 86 1 184 73 1 184 73 1 184 73 1 184 73 408 38 408 38 622 74 622 74 638 78 638 78 638 78 638 78 638 78 666 65 666 65 666 65 666 65 1 253 37 1 253 37 1 253 37 1 253 37 1 253 37 60 14 60 14 60 14 60 14 60 14 60 14 60 14 12 85 12 85 DATE 9 14 2006 9 14 2006 9 14 2006 9 14 2006 9 14 2006 5 1 2007 5 1 2007 7 5 2007 7 5 2007 12 11 2007 12 11 2007 12 11 2007 12 11 2007 12 11 2007 8 15 2008 8 15 2008 9 1 2008 9 1 2008 12 17 2008 12 17 2008 12 17 2008 12 17 2008 12 17 2008 11 26 2009 11 26 2009 11 26 2009 11 26 2009 11 26 2009 4 14 2010 4 14 2010 4 14 2010 4 4 2010 4 4 2010 1 20 2006 2 15 2006 3 17 2006 4 19 2006
52. orney of Medicare s priority right of recovery as defined under the Medicare Secondary Payer provisions Because you were involved in an automobile slip and fall medical malpractice or some other type of liability claim the medical expenses are subject to reimbursement to Medicare from proceeds received pursuant to a third party liability settlement award judgment or recovery 00018 AA OFF RA ST En 193 EFRAIN FROM MAKING PAYMENT AT THIS TIME However we request that you your attorney refrain from sending any monies to Medicare prior to submission of settlement information and receipt of a demand recovery calculation letter from our office This will eliminate underpapmenis overpayments racc ne pagan dalarra ana or associ ated ST M ne MEN M CM PIC UM MEI MCI ET E uS au Cm I REC dut Currently Medicare has paid 38 850 99 in conditional payments related to your claim Attached you your attorney will find a listing of claims that comprise this total Please take a look at this listing and let us know if you your attorney disagree with the inclusion of any claim in whole or in part and explain the reasons why you your attorney disagree s Please be advised that we are still investigating this case file to obtain any other outstanding Medicare conditional payments Therefore the enclosed listing of current conditional payments including a response of a zero
53. ould be used when you the Medicare beneficiary want to inform the Centers for Medicare amp Medicaid Services CMS that you have given another individual the authority to represent you and act on your behalf with respect to your claim for liability insurance no fault insurance or workers compensation including releasing identifiable health information or resolving any potential recovery claim that Medicare may have if there is a settlement judgment award or other payment You are not required to use this model language but proof of representation must include the information provided in this model language Your representative must also sign that he she has agreed to represent you This model language also makes provisions for the information your representative must provide Type of Medicare Beneficiary Representative Check one below and then print the requested information Individual other than an Attorney Name Attorney Relationship to the Medicare Beneficiary Guardian Firm or Company Name Conservator Address Power of Attorney Telephone Note If you have an attorney your attorney may be able to use his her retainer agreement instead of this language If the beneficiary is incapacitated his her guardian conservator power of attorney etc will need to submit documentation other than this model language Please visit http go cms gov cobro for further instructions Medicare Beneficiary I
54. pically associated with the MSP recovery process since you will not have to wait for Medicare to determine the conditional payment amount prior to settlement You may elect the Fixed Percentage Option if the following eligibility criteria are met A Your liability insurance including self insurance settlement judgment award or other payment is related to an alleged physical trauma based incident and B The total settlement is for 5 000 00 or less THE SELF CALCULATED CONDITIONAL PAYMENT OPTION This option enables you to self calculate the final conditional payment amount before settlement in certain situations The following conditions must be met for Medicare to provide the final conditional payment amount before settlement is reached A The claim and settlement must be for an injury caused by physical trauma The settlement cannot involve or relate to injuries caused by exposure ingestion or medical implant B Your medical treatment for the injury must be completed with no further treatment expected Treatment must have been completed at least 90 days before you submit the proposed conditional payment amount to Medicare These requirements are proven to Medicare by providing either physician s written confirmation or beneficiary certification that he she has not had care related to the case within the last 90 days and expects no further care 00007 The total settlement judgment award or other payment canno
55. re Number Entitlement Date June 01 1990 Date of Incident January 01 2006 Case Identific tion Number DCN Dear HOLLOWELL LAW FIRM This letter is in reference to a request received from HOLLOWELL LAW FIRM dated April 03 2014 to remove claims from Medicare s demand letter dated March 31 2014 that are not related to your case After reviewing the claims in question we Partially Agree with your dispute Therefore in accordance with this decision the un related claims have been removed from the demand amount The amount due through April 22 2014 is 11 939 65 The principal amount is 11 939 65 and the interest amount is 0 00 If this debt remains outstanding after June 08 2014 the amount due including interest will be 11 939 65 Please be advised that interest will continue accruing every 30 days thereafter until the balance is paid RNA Please make your check payable to Medicare in the amount of 11 939 65 and send to the address below When sending any correspondence please provide the Beneficiary Name and Medicare Health Insurance Claim Number the number on the Medicare card This will allow us to associate the correspondence to the appropriate records If you have any questions concerning this matter please call the Benefits Coordination amp Recovery Center BCRC at 1 855 798 2627 TTY TDD 1 855 797 2627 for the hearing and speech impaired or you may contact us in writing at the address below NGHP P O
56. t exceed 25 000 00 The date of the incident must have occurred at least six months before submitting the self calculated final conditional payment amount to Medicare You will be asked to give up the right to appeal the amount or existence of the debt However you will keep the right to pursue waiver of recovery 00008 The Medicare Secondary Payer Recovery Portal MSPRP The Medicare Secondary Payer Recovery Portal MSPRP is a web based tool designed to assist in the resolution of Liability Insurance No Fault Insurance and Workers Compensation Medicare recovery cases The MSPRP gives you the ability to access and update certain case specific information online MSPRP Features amp Benefits The MSPRP provides you with the following features and related benefits 1 Submit a Proof of Representation OR Consent To Release documentation 2 Request conditional payment information Request an updated Conditional Payment Amount Request a copy of a current Conditional Payment Letter 3 Dispute claims included in the Payment Summary Form s attached to the CPL View the claims listed on the Conditional Payment Letter s Payment Summary Form s and dispute unrelated claims Upload documentation to support the claim dispute 4 Submit case settlement information Input settlement information and upload a copy of the settlement documentation How To Access The MSPRP Attorneys and Insurers will access the MSPRP using the MS
57. ty five 45 days See Form J Once you receive this response from BCRC See Form K if you are dis satisfied you will then appeal in accordance with the instructions in said letter The Lucy May Example Form K is the Final Demand Letter from BCRC without the Procurement Costs reduction Therefore you should respond by preparing another Procurement Cost s Worksheet See Form and submitting it with a check for the new amount you have to the address set out in the Final Demand Letter The BCRC 5 LEVEL Administrative Appeal Process Steps Receive Conditional Payment Letter from BCRC with Payment Summary Forms attached Payment Summary Forms include detailed information such as dates organizations ICD 9 Codes etc Send BCRC a REQUEST FOR REDETERMINATION With ALL supporting documents attached i e medical records related unrelated claims worksheet Procurement Cost Worksheet within one hundred twenty 120 days Receive notice letter from BCRC of Redetermination Decision either reducing the beneficiaries lien according to the supporting documentation you sent in or the BCRC s lien amount stays the same with their reasons as to why listed in the notice letter within sixty 60 days May want to Appeal to next level Send Request for Redetermination to party listed in BCRC s notice and or letter of response 1 a Qualified Independent Contractor QIC Send all requested information and or doc
58. umentation they will first attempt to contact you by phone however if they are unsuccessful they will mail you a letter 3 00003 5 You should receive the Conditional Payment Letter CPL See Form within sixty five 65 days of the date on the Rights And Responsibilities RAR letter The Conditional Payment Letter includes the amount BCRC claims to be related Further they will attach a Payment Summary Form s PSF See Form F NOTE A Conditional Payment Notice CPN is issued in lieu of a CPL when a settlement judgment award or other payment has already occurred Once you receive this CPN you must respond within thirty 30 days or you will lose all rights to reductions for_fees or costs Prepare a Related Unrelated Worksheet See Form G based on the DIAGNOSIS ICD codes listed on the Payment Summary Form s After preparing your summary you will then decide if you want to dispute the BCRC claim set out in the CPL If you are satisfied with the amount in the CPL fax a Final Settlement Detail Document Form to BCRC requesting a Final Demand Letter be generated You should include an executed Settlement Agreement Employment Contract Attorney s expense s Sheet Disbursement Sheet if applicable and your Procurement Cost Worksheet See Form I In the Final Settlement Detail Document make sure you reduce the amount owed BCRC
59. uments with your request and any other supporting documentation within one hundred and eighty 180 days Receive notice letter from BCRC QIC of Redetermination Decision within sixty 60 days May want to Appeal to next level Send a Request for Hearing before an Administrative Law Judge ALJ if you have 140 00 in controversy you have sixty 60 days to appeal Include any information and or documentation they request and any other supporting documentation you feel necessary to support your claim s You will receive a Notice Of ALJ Hearing with date time name of the Administrative Law Judge ALJ and any other pertinent information for a telephonic Hearing You 00005 LEVEL 4 LEVEL 5 must send a copy of ALJ Request For Hearing to all parties of the QIC s decision This is usually a unilateral Hearing in other words Medicare does not participate Depending upon the decision made from the telephonic Hearing the next steps may be required The decision will be given within ninety 90 days Fill out and send a Request for Review of an Administrative Law Judge ALJ Medicare Decision Dismissal form including any requesting information documentation they may ask for and any other supporting documentation to support your claim s within sixty 60 days You should receive a written decision within ninety 90 days from the Appeals Council If you disagree with the Council s decision in Level four 4

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