Medicare Advantage and Prescription Drug Plans December 28 ...

Plan Communications User Guide Appendices, Version 6.3
J.3 HMO Bill Itemization Report
Description
This report lists the Part A bills processed under Medicare fee-for-service for beneficiaries enrolled in the contract.
Example
1 PART A BILLS POSTED IN OCT 2002 PAGE 1
BILL TYPE: INPATIENT
* * * * * HMO H4444 * * * * *
HMO ADM TOTAL NON-COV INP NC BLD COINSURANCE TOTAL FROM THRU COV REIM NP
CLAIM NUM NAME PROV INTER PD DATE CHARGES CHARGES DED DEDUCT DAYS CHGS AMOUNT DEDUCT DATE DATE
DAYS AMT CD CR
123456789A BAKER 010084 00010 20020630 7821 0 812 0 0 0 0 812 20020630 20020703 0 0
123456789C2 MILLER 014007 00010 20020819 8320 8320 0 0 0 0 0 0 20020819 20020920 0 0 N
1 PART A BILLS POSTED IN OCT 2002 PAGE 2
* * * * * HMO H4444 * * * * *
BILL TYPE: HOSPICE
HMO ADM TOTAL NON-COV INP NC BLD COINSURANCE TOTAL FROM THRU COV REIM NP
CLAIM NUM NAME PROV INTER PD DATE CHARGES CHARGES DED DEDUCT DAYS CHGS AMOUNT DEDUCT DATE DATE
DAYS AMT CD CR
1234567891 CANDLE 011570 00380 20020826 3084 0 0 0 0 0 0 0 20020901 20020930 0 3084
12345678946 FLICKE 011570 00380 20020912 1953 0 0 0 0 0 0 0 20020912 20020930 0 1953
December 28, 2012 J-11 HMO Bill Itemization Report