Explanation of Monthly Statement of Account - MC2323-13 by sew21405


									                        Explanation of Monthly Statement of Account
                        Mayo Clinic, Saint Marys Hospital and Rochester Methodist Hospital

                        Below is a visual guide to the monthly statement of account. This shows what
                        your insurance company has paid, any amount still under consideration by
                        your insurance company, and what amount you should pay now.

                                                                                                                                                                                                                                        Added insurance
                                                                                                                                                                                                                                        claims pending column
                                                                                                                                                                                                 of A thly S
                                                                                                                                                                                                     ccou tate
                                                                                                                               May nt Nam                                                                nt    men
                                                                                                                              Date Clinic
                                                                                                                                            e                                                                      t
                                                                                                                             Plac s of Se umber/
                                                                                                                                 e       rv          Visit
                                                                                                                            Tran of Ser ice                  Num
                                                                                                                                sact     v
                                                                                                                                     ion ice                     ber
                                                                                                                          DO            Deta
                                                                                                                              E              il/D
                                                                                                                         1-2 , JOH                escri
                                                                                                                        01/0 4-567 N                    ptio
                                                                                                                       St. 8/200 Visit
                                                                                                                           Mar 5 -         500
                ont ount
                                                                                                                              ys                                                                                                                                 Pag
                                                                                                                                 Hos 1/08/2 8                                                                                                                       e2
                                                                                                                     Pre              pita 005
               M cc                                                                                                 11/1 vious            l

               of A
                                                                                                                        9/01 Bala
                                                                                                                             Per nce
                                                                                                                                son                                                                                      Acc
                                                                                                                                    al P                                                                                     o
                                                                                                                                             ent                                                                        Activ unt
                                                                                                                                                                                                                             ity                       Insu
                                                                                                            DO - 4    582                                                                                                                                   ra
                                                                                                           6 20E
                                                                                                          -1-6 , JO                                              Vis                                                                                  Pen s
                                                                                                      800 01/034-567HN                                               it
                                                                                                                                                                Ins Bala                                                                                  ding
                                                                                                           May 6/200 Visit                                         u
                                                                                                                                                               Am rance nce
                                                                                                                oC 5-0          5                                  oun                                                                                                      Pe
                                                                                                                   linic 1/0 800                                        t DuPendin                      $                                                                Res rsonal
                                                                                                         Pre             Roc 8/200                                          e      g                   $                                                                    pons
                                                                                                                             hes 5                                                                                  37.                                                          ibilit
                                                                                                        11/1 vious                ter                                                                 $
                                                                                                                                                                                                                   37. 38                                                               y
                                                                                                            9/01 Bala                                                                                                 3
                                                                                                                 ABC nce                                                                                           0.0 8-
                                                                                                                       Insu                                                                                            0
                                                                                                                                       me     nt
                                                                                                 DO                                                                                                                                               0.0
                                                                                                2-3 , JAN                                             Vis                                                                                               0
                                                                                                    45-      E                                            it
                                                                                               01/3 678                                             Ins Bala
                                                                                              Roc 0/200 Visit                                           u
                                                                                                                                                   Am rance nce                                                                                              $
                                                                                                   hes 5 - 0          5                                 oun
                                                                                                       ter       1/30 030                                    t DuPendin                     $
                                                                                                            Met                                                                                                                                                          0.0
                                                                                           New                   hod /2005                                        e      g                 $           315                                                                     0
                                                                                         11/2 Char                    ist                                                                 $           250 .85
                                                                                               7/01 ges                   Hos                                                                            .
                                                                                                     Insu                      pita                                                                   65. 00
                                                                                                           ran                                                                                            85
                                                                                                               ce C
                                                                                                                          File                                                                                      $
                                                                                 DO                                                     Insu
                                                                                       E                                                     ra                                                                                         0.0
                                                                                2-3 , JAN                                                Vis nce                                                                                              0
                                                                                      45-        E                                           it
                                                                               01/2 678                                                 Ins Bala
                                                                                      9/20                                                  u
                                                                              May            05 Visit 5                               Am rance nce                                                                                                $
                                                                                     oC                                                    oun
                                                                                          linic - 01/3 800                                      t DuPendin                     $
                                                                            New                  Roc 0/200                                            e        g                          286                                                                      85
                                                                                                      hes 5
                                                                           11/2 Char                       ter                                            ncy.               $                  .40
                                                                               2/01 ges                                                            c urre
                                                                                        Insu                                                   end                                      286
                                                                                              ran                                         ot s                                                .40
                                                                                                  ce C                               Do n                            sed
                                                                                                        laim                   ent.                            Enclo
                                                                                                              File ur paym                                unt
                                                                                                                    /AB                             Amo                                                $
                                                                                                                ith     C In
                                                                                                           nt w              sura                                                                                  286
                                                                                                      eme                            cD
                                                                                                                                        ue                                                                               .40
                                                                                                 stat                       Vis unt e
                                                                                            this                            Amo it
                                                                                                                           Ins Bala
                                                                                      n of                                     u
                                                                             por t
                                                                                   io                                     Am rance nce                                     70.                                                          $
                                                                          er                                Due               oun
                                                                                                                                   t DuPendin                        $ -56
                                               Payment          Policy low
                                                                    the                              Date                                e        g            507
                                                                                                                                                                   -266                                                                            0.0
                                                                eturn                         er                                                                 ll            rd
                                                                                                                                                                                  terca1 8 . 2 9
                                                                                                                                                                                      5                                                                  0
                                                           se r                           umb                                                              or ca        $
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                                                                                                 N                                             rd:    low,
                                                       nt, p will receive a statement each month if your account has a be
                                                                                       Acc                                          ebi
                                                                                                                                        t ca sign balance due.    lub              5
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                                                  yme                                                                                       and             ers C
                                                                                 ling not received payment from it/d insurance company within 45 days, 9 look to you for full
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                                                                             B                                            edyour tion                   Din                                  we
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                                                                                                                                                                                        Da                     518
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                                                                . Plea                      b er                         r      ce erunt
                                                        ha nged                       t num losed                   ebit entt AmCb ims Balan
                                                                                                                                  um la                                                                                 $
                                                    Please review thisostatement carefully. WeDwelcomeNany nt Pen ceyou may have about your account and invite you
                                                   as c                         c un e enc                                  un       ou questions
                                              ss h           r:           g ac                                         Acco
Detailed/                                                              li by in th                                                          D e ding                                                                                    0.0
                                    ur a
                                         ddre       to orde our us n matelephone or letter (see contact informationubelow). We will make every attempt to answer your
                                                     y contact bil d il                                           Card                                     $                                                                                  0
                           re if
                                 yo            one         te y
                                                    questions r an                                                                                                     8 7 0 addressed, please contact Mayo
                      k he             or m IC. Wri y ordeconcerning your account. If you feel that ard                          your concerns have not been . 5 4
                                                                                                                                                                                                                                                        Added summary
                                                                                                                               C                                                                          605
                 Chec              ck           IN one                                                                   e on

                             che AYO CL oClinic Patient Account Services at 1-800-660-4582 or 507-266-5670 to allow us the opportunity 2to try to address your
                                                    rm                                                               Nam                                                                      MC
                   a y by         to  M heck concerns. Or, you have the option to address any concerns re                                  tu with the Minnesota Attorney$ General’s                             which can
               To p payable f your c                                                                                                  igna
                Mak e front :
                 on th lope to
                                 o                  be reached at 651-296-3353 or 1-800-657-3787.
                                                                                                                                   dS                                                              804
                                                                                                                                                                                                           .69                                          of each visit
                                                    For United States and Canadian                                                           For international
- amount                                            patient inquiries:              Patient Account Services
                                                                                    Mayo Clinic
                                                                                                                                             patient inquiries: International Financial Services
                                                                                                                                                                        Mayo Clinic
                                                                                                                                                                                                                            8   5
  pending                                                                   LC-LL-B180 PFS
                                                                            200 First Street SW
                                                                                                                                                                  200 First Street SW
                                                                                                                                                                  Rochester, MN 55905 USA
                                                                            Rochester, MN 55905                                                                   Telephone: 001-507-538-4019
  insurance                                                                 Telephone: 1-800-660-4582 or 507-266-5670                                             Fax: 001-507-284-0688

- current                                       Glossary of Terms

  amount due
                                                Adjustments/Payments: A credit or debit transaction
                                                applied to the account.
                                                                                                                                     Insurance Claims Pending: Charges     to insurance
                                                                                                                                     company; Mayo Clinic has not received a determination of
                                                                                                                                                                                                                                                  New glossary of
                                                Billing Account Number: The account number of the
                                                                                                                                     the                                                                                                          billing terms
                                                person assigned to receive the bill. Refer to this                                   Mayo Clinic Number: The patient’s personal
                                                number when contacting Mayo Clinic with questions.                                   number.

                                                Billing Addressee: The person designated to receive the                              New Charges: Charges billed by Mayo Clinic since the
                                                monthly billing statements. This person can coordinate                               previous monthly statement. These are detailed on your
                                                                                                                                     Itemized Statement of Charges.
                                                the billing, payment and insurance coverage for the
                                                                                                                                     Visit Balance: The current balance of each episode of care.
                                                Contract Adjustment: A credit or debit applied to the                                Visit Number: A number assigned to identify each
                                                account due to the contractual agreement between                                     episode of care. The number is used to track services and

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