Below is a sample MSN for Part B services with explanations of the information you will find in each section. Part B services may include Part B services include doctors’ services, outpatient hospital care and home health care.
6. Part B Medical Insurance - Assigned Claims: Type of service. See back of MSN for information about assignment. (Note: For unassigned services, this section is called “Part B Medical Insurance—Unassigned Claims.”)
7. Claim Number: Number that identifies this specific claim.
8. Provider’s Name and Address: Doctor (may show clinic, group, and/or referring doctor) or provider’s name and billing address.
9. Dates of Service: Date service or supply was received. You may use these dates to compare with the dates shown on the bill you get from your doctor.
10. Amount Charged: Amount the provider billed Medicare.
11. Medicare Approved: Amount Medicare approves for this service or supply.
12. Medicare Paid Provider: Amount Medicare paid to the provider. (Note: For unassigned claims, this column is called “Medicare Paid You.”)
13. You May Be Billed: Total amount provider may bill you, including deductibles, coinsurance, and non-covered charges. Medigap (Medicare Supplement Insurance) policies may pay all or part of this amount.
14. See Notes Section: If letter appears, refer to (16) for explanation.
15. Services Provided: Brief description of the service or supply received.