MSN - Specifications for Section 3: Claims (Rev. 3210, 04-16-15)

by  Jared Staheli
August 10th, 2015

A. Section Title

POSITION

This subsection contains information of a fixed size. It is fixed in width but may vary in overall length.

The content area begins (0˝, 0.22˝), 7 points from the baseline of the content described above under the Headers for Other Pages subsection. It is full-page or 540 points in width and variable in height.

DYNAMIC RULES

The language in this section varies for different members of the extended family of MSNs. See the specific content specifications below for details.

When there is a combined MSN for Part A, order the claims as follows:

• Part A Inpatient

• ‘B of A’

• Home Health

• Hospice

When there is a combined MSN for Part B or DME, order the claims as follows:

• Assigned

• Unassigned

PART A INPATIENT SPECIFICATIONS

CONTENT

Your Inpatient Claims for Part A (Hospital Insurance)

HOSPICE SPECIFICATIONS

CONTENT

Your Hospice Claims for Part A (Hospital Insurance)

HOME HEALTH SPECIFICATIONS

CONTENT

Your Home Health Claims for Part A (Hospital Insurance)

PART B ASSIGNED AND DME ASSIGNED SPECIFICATIONS

CONTENT

Your Claims for Part B (Medical Insurance)

PART B UNASSIGNED AND DME UNASSIGNED SPECIFICATIONS

CONTENT

Your Unassigned Claims for Part B (Medical Insurance)

‘B OF A’ SPECIFICATIONS

CONTENT

Your Outpatient Claims for Part B (Medical Insurance)

B. Definitions of Columns

GLOBAL SPECIFICATIONS

POSITION

The subsection usually begins (0˝, 0.94˝) or 28 points from the baseline of the Section Title subsection. The content area is full-page or 540 points in width but is divided into two columns, each column 259 points in width with 22 point gutter in between. The height is variable, depending on the length of the content, which is determined by the member of the extended family to which the MSN belongs. The left column should always be longer than the right column. If a definition is split between the columns, there should be at least two lines on both left and right columns.

DYNAMIC RULES

The language in this section differs for each member of the extended family of MSNs. See the specific content specifications below for details.

PART A INPATIENT SPECIFICATIONS

CONTENT

Part A Inpatient Hospital Insurance helps pay for inpatient hospital care, inpatient care in a skilled nursing facility following a hospital stay, home health care, and hospice care.

Definitions of Columns

Benefit Days Used: The number of covered benefit days you used during each hospital and/or skilled nursing facility stay. (See page 2 for more information and a summary of your benefit periods.)

Claim Approved?: This column tells you if Medicare covered the inpatient stay.

Non-Covered Charges: This is the amount Medicare didn’t pay.

Amount Medicare Paid: This is the amount Medicare paid your inpatient facility.

Maximum You May Be Billed: The amount you may be billed for Part A services can include a deductible, coinsurance based on your benefit days used, and other charges.

For more information about Medicare Part A coverage, see your “Medicare & You” handbook.

HOSPICE SPECIFICATIONS

CONTENT

Part A Hospital Insurance helps pay for inpatient hospital care, inpatient care in a skilled nursing facility following a hospital stay, home health care, and hospice care.

Definitions of Columns

Service Approved?: This column tells you if Medicare covered the hospice service.

Amount Provider Charged: This is your provider’s fee for this service.

Medicare-Approved Amount: This is the amount a provider can be paid for a Medicare service. It may be less than the actual amount the provider charged. Your provider has agreed to accept this amount as full payment for covered services. Medicare usually pays 80% of the Medicare-approved amount.

Amount Medicare Paid: This is the amount Medicare paid the provider. This is usually 80% of the Medicare-approved amount.

Maximum You May Be Billed: This is the total amount the provider is allowed to bill you. This is usually $0, but can include copayments for outpatient prescription drugs, as well as 5% of the Medicare- approved amount for inpatient respite care. If you have Medicare Supplement Insurance (Medigap policy) or other insurance, it may pay all or part of this amount.

HOME HEALTH SPECIFICATIONS

CONTENT

Part A Hospital Insurance helps pay for inpatient hospital care, inpatient care in a skilled nursing facility following a hospital stay, home health care, and hospice care.

Definitions of Columns

Service Approved?: This column tells you if Medicare covered the home health service.

Amount Provider Charged: This is your provider’s fee for this service.

Medicare-Approved Amount: This is the amount a provider can be paid for a Medicare service. It may be less than the actual amount the provider charged. Your provider has agreed to accept this amount as full payment for covered services. Medicare usually pays 80% of the Medicare-approved amount.

Amount Medicare Paid: This is the amount Medicare paid the provider. This is usually 80% of the Medicare-approved amount.

Maximum You May Be Billed: This is the total amount the provider is allowed to bill you. This is usually $0. For durable medical equipment, it can include 20% of the Medicare-approved amount. If you have Medicare Supplement Insurance (Medigap policy) or other insurance, it may pay all or part of this amount.

PART B ASSIGNED SPECIFICATIONS

CONTENT

Part B Medical Insurance helps pay for doctors’ services, diagnostic tests, ambulance services, and other health care services.

Definitions of Columns

Service Approved?: This column tells you if Medicare covered this service.

Amount Provider Charged: This is your provider’s fee for this service.

Medicare-Approved Amount: This is the amount a provider can be paid for a Medicare service. It may be less than the actual amount the provider charged. Your provider has agreed to accept this amount as full payment for covered services. Medicare usually pays 80% of the Medicare-approved amount.

Amount Medicare Paid: This is the amount Medicare paid your provider. This is usually 80% of the Medicare-approved amount.

Maximum You May Be Billed: This is the total amount the provider is allowed to bill you, and can include a deductible, coinsurance, and other charges not covered. If you have Medicare Supplement Insurance (Medigap policy) or other insurance, it may pay all or part of this amount.

PART B UNASSIGNED SPECIFICATIONS

CONTENT

Medicare claims may be assigned or unassigned. Your claims below are unassigned—meaning the provider hasn’t agreed to accept the Medicare-approved amount as payment in full.

Do Unassigned Claims Cost More? Maybe. A provider who doesn’t accept assignment may charge you up to 15% over the Medicare-approved amount. This is known as the limiting charge. You may have to pay this amount, or it may be covered by another insurer.

For a list of providers that always accept Medicare assignment, visit www.medicare.gov/physician or call 1-800-MEDICARE (1-800-633- 4227). You may save money by choosing providers who accept assignment.

Definitions of Columns

Service Approved?: This column tells you if Medicare covered the service.

Amount Provider Charged: This is your provider’s fee for this service.

Medicare-Approved Amount: This is the amount a provider can be paid for a Medicare service. Since your provider hasn’t agreed to accept assignment, you might be charged up to 15% more than this amount. Medicare usually pays 80% of the Medicare-approved amount.

Medicare Paid You: When a provider doesn’t accept assignment, Medicare pays you directly. You’ll usually get 80% of the Medicare-approved amount.

Maximum You May Be Billed: This is the total amount the provider is allowed to bill you and can include a deductible, coinsurance, and other charges not covered. If you have Medicare Supplement Insurance (Medigap policy) or other insurance, it may pay all or part of this amount.

‘B OF A’ SPECIFICATIONS

CONTENT

Part B Medical Insurance helps pay for outpatient care provided by certified medical facilities, such as hospital outpatient departments, renal dialysis facilities, and community health centers.

Definitions of Columns

Service Approved?: This column tells you if Medicare covered the outpatient service.

Amount Facility Charged: This is the facility’s fee for this service.

Medicare-Approved Amount: This is the amount a facility can be paid for a Medicare service. It may be less than the actual amount the facility charged. The facility has agreed to accept this amount as full payment for covered services. Medicare usually pays 80% of the Medicare-approved amount.

Amount Medicare Paid: This is the amount Medicare paid the facility. This is usually 80% of the Medicare-approved amount.

Maximum You May Be Billed: This is the total amount the facility is allowed to bill you, and can include a deductible, coinsurance, and other charges not covered. If you have Medicare Supplement Insurance (Medigap policy) or other insurance, it may pay all or part of this amount.

DME ASSIGNED SPECIFICATIONS

CONTENT

Part B Medical Insurance helps pay for durable medical equipment and other health care services.

Definitions of Columns

Item/Service Approved?: This column tells you if Medicare covered this item or service.

Amount Supplier Charged: This is your supplier’s fee for this item or service.

Medicare-Approved Amount: This is the amount a supplier can be paid for a Medicare item or service. It may be less than the actual amount the supplier charged. Your supplier has agreed to accept this amount as full payment for covered items or services. Medicare usually pays 80% of the Medicare-approved amount.

Amount Medicare Paid: This column shows the amount Medicare paid the supplier. This is usually 80% of the Medicare-approved amount.

Maximum You May Be Billed: This is the total amount the supplier is allowed to bill you, and can include a deductible, coinsurance, and other charges not covered. If you have Medicare Supplement Insurance (Medigap policy) or other insurance, it may pay all or part of this amount.

DME UNASSIGNED SPECIFICATIONS

CONTENT

Medicare claims may be assigned or unassigned. Your claims below are unassigned—meaning the supplier hasn’t agreed to accept the Medicare-approved amount as payment in full.

Do Unassigned Claims Cost More? Maybe. A supplier who doesn’t accept assignment may charge you up to 15% over the Medicare-approved amount. This is known as the limiting charge. The limiting charge applies only to certain Medicarecovered services and doesn’t apply to some supplies and durable medical equipment. You may have to pay this amount, or it may be covered by another insurer.

For a list of suppliers that always accept Medicare assignment, visit www.medicare.gov/supplier or call 1-800-MEDICARE (1-800-633- 4227). You may save money by choosing suppliers who accept assignment.

Definitions of Columns

Service Approved?: This column tells you if Medicare covered the item or service.

Amount Provider Charged: This is your supplier’s fee for this item or service.

Medicare-Approved Amount: This is the amount a supplier can be paid for a Medicare item or service. It may be less than the actual amount the supplier charged. Since your supplier hasn’t agreed to accept assignment, you might be charged more than this amount (see “Do Unassigned Claims Cost More” to your left). Medicare usually pays 80% of the Medicare-approved amount.

Medicare Paid You: When a supplier doesn’t accept assignment, Medicare pays you directly. You’ll usually get 80% of the Medicare-approved amount.

Maximum You May Be Billed: This is the total amount the supplier is allowed to bill you and can include a deductible, coinsurance, and other charges not covered. If you have Medicare Supplement Insurance (Medigap policy) or other insurance, it may pay all or part of this amount.

For more information about Medicare assignment, see your “Medicare & You” handbook.

C. Claim Header

GLOBAL SPECIFICATIONS

This subsection contains the name and contact information for the provider and/or referrer of each claim. It also lists the date (or dates) of service for the claim. See Exhibit 2.5 for multiple examples of this section, showing provider and contact information variations among extended family members. See Exhibit 2.6 for multiple examples of claim headers indicating multiple dates of service.

The sort order for claims is determined by the date of service listed in this section. Claims should be listed by earliest date of service, using the first date of service in a given claim.

For multiple claims with the same earliest date of service, the claims are sorted chronologically by last date of service.

For multiple claims with the same first and last date of service, the claims are sorted alphabetically by billing facility name, provider last name, or supplier name.

For multiple claims with the same first and last date of service and the same billing provider, the claims are sorted by Maximum You May be Billed Amount, with the claim with the lowest amount listed first.

POSITION

This subsection is full-page or 540 points in width and starts 19 points below the definitions of columns. The height is variable, depending on the length of the content, which may be three or four lines high.

Indent in 8 points all around for content area. Note: Space after the black rule should be 8 points, rather than the typical 6 points specified in the style sheet.

The facility/provider/supplier line has a maximum of 40 characters, same as on page 1 on the ‘Facility/Provider/Supplier List’ subsection. The phone number has a maximum of 30 characters, to include area code and/or any international numbers for U.S. territories. The address line has a maximum of 80 characters. If the address exceeds the maximum character limit, truncate the second address line to fit the address in one line. The referred or ordering provider line also has a maximum of 40 characters. 

PART A INPATIENT, HOSPICE, HOME HEALTH AND ‘B OF A’ SPECIFICATIONS

DYNAMIC RULES

The content in this section is nearly entirely dynamically generated. It includes the following content elements:

Date(s) of Service

The date of service is listed with a spelled-out month, numeric day, and complete numeric year (e.g., October 15, 2021).

If a single claim includes multiple dates of service, list the first and last date of service for the claim, separated by an en-dash; insert spaces to either side of the en-dash.

If both the first and last dates are within the same calendar year, drop the year from the first date (e.g., October 15 – November 3, 2021). If the dates are in different calendar years, keep the year in both dates (e.g., October 15, 2021 – January 3, 2022).

Facility Name

Print the complete name of the inpatient facility, hospice facility or provider, or home health provider that filed the claim for services.

Facility Phone Number

Print the facility or provider’s 10-digit phone number, preceded by a comma to separate it from the facility or provider name. Enclose the area code within parentheses. Insert a dash between the third and fourth digit of the local phone number.

If available, print the phone number associated with the billing department of the facility or provider that filed the claim for services. If a specific billing contact number is not available, print the primary phone number for the facility or provider. If no phone number for the facility or provider is available, suppress this content element and its preceding comma.

Facility Address

Print the facility or provider’s street address, city, state abbreviation, and ZIP code +4. Insert a comma between the street address and city, and between the city and state abbreviation.

If available, print the physical address of the facility or provider. If the physical address is not available, print the mailing or billing address for the facility or provider. If no address for the facility or provider is available, suppress this content element.

Referring Provider

If the beneficiary was referred by a provider, print the provider’s full name here, preceded by the phrase “Referred by”. When printing a degree suffix (e.g., M.D.) with a name, place a period after the “M” and after the “D.” Referring physician name and any suffix should be separated by a comma.

CONTENT

{Date(s) of Service}

{Facility/Provider Name}, {10-digit phone number for facility/provider} {Facility/Provider Street Address}{Facility/Provider State}{Facility/Provider ZIP+4}

Referred by {Provider Title}{Provider Given Name}{Provider Middle Initial}{Provider Family Name}

PART B (ASSIGNED AND UNASSIGNED) SPECIFICATIONS

DYNAMIC RULES

The content in this section is nearly entirely dynamically generated. It includes the following content elements:

Date(s) of Service

The date of service is listed with a spelled-out month, numeric day, and complete numeric year (e.g., October 15, 2021).

If a single claim includes multiple dates of service, list the first and last date of service for the claim, separated by an en-dash; insert spaces to either side of the en-dash.

If both the first and last dates are within the same calendar year, drop the year from the first date (e.g., October 15 – November 3, 2021). If the dates are in different calendar years, keep the year in both dates (e.g., October 15, 2021 – January 3, 2022).

Provider Name

Print the complete name of the provider that filed the claim for services. When printing a degree suffix (e.g., M.D.) with a name, place a period after the “M” and after the “D.” The name and any suffix should be separated by a comma.

Provider Phone Number

Print the provider’s 10-digit phone number, preceded by a comma to separate it from the provider name. Enclose the area code within parentheses. Insert a dash between the third and fourth digit of the local phone number.

If available, print the phone number associated with the billing department of the provider that filed the claim for services. If a specific billing contact number is not available, print the primary phone number for the provider. If no phone number for the provider is available, suppress this content element and its preceding comma.

Provider Practice Name and Address

If applicable, print the name of the practice or facility associated with the provider. Print the provider’s street address, city, state abbreviation, and zip code +4. Insert a comma between the practice name, street address and city, and between the city and state abbreviation.

Whenever possible, the address that is printed should be the physical address of the provider. If the physical address is not available, use the mailing or billing address for the provider. If no address for the provider is available, suppress this content element.

Referring Provider

If the beneficiary was referred to the provider by another provider, print the referring provider’s full name here, preceded by the phrase “Referred by”. When printing a degree suffix (e.g., M.D.) with a name, place a period after the “M” and after the “D.” Referring provider name and any suffix should be separated by a comma.

CONTENT

{Date(s) of Service}

{Provider Title}{Provider Given Name}{Provider Middle Initial}{Provider Family Name} {, Provider Suffix}, {10-digit phone number for provider}

{Provider Practice Name}{Provider Street Address}{ Provider State}{ Provider ZIP+4}

Referred by {Provider Title}{Provider Given Name}{Provider Middle Initial}{Provider Family Name}

DME (ASSIGNED AND UNASSIGNED) SPECIFICATIONS

DYNAMIC RULES

The content in this section is nearly entirely dynamically generated. It includes the following content elements:

Date(s) of Service

The date of service is listed with a spelled-out month, numeric day, and complete numeric year (e.g., October 15, 2021).

If a single claim includes multiple dates of service, list the first and last date of service for the claim, separated by an en-dash; insert spaces to either side of the en-dash.

If both the first and last dates are within the same calendar year, drop the year from the first date (e.g., October 15 – November 3, 2021). If the dates are in different calendar years, keep the year in both dates (e.g., October 15, 2021 – January 3, 2022).

Supplier Name

Print the complete name of the supplier that filed the claim for services. If the supplier is a physician, when printing a degree suffix (e.g., M.D.) with the name, place a period after the “M” and after the “D.” The name and any suffix should be separated by a comma.

Supplier Phone Number

Print the supplier 10-digit phone number, preceded by a comma to separate it from the supplier name. Enclose the area code within parentheses. Insert a dash between the third and fourth digit of the local phone number.

If available, print the phone number associated with the billing department of the supplier that filed the claim for services. If a specific billing contact number is not available, print the primary phone number for the supplier. If no phone number for the supplier is available, suppress this content element and its preceding comma.

Supplier Address

Print the supplier’s street address, city, state abbreviation, and ZIP code +4. Insert a comma between the practice name, street address and city, and between the city and state abbreviation.

If available, print the physical address of the supplier. If the physical address is not available, print the mailing or billing address for the supplier. If no address for the supplier is available, suppress this content element.

Ordering Provider

If the beneficiary’s supplies were ordered by a provider, print the ordering provider’s full name here, preceded by the phrase “Ordered by”. When printing a degree suffix (e.g., M.D.) with a name, place a period after the “M” and after the “D.” Ordering physician name and any suffix should be separated by a comma. If the NPI submitted on the claim is not on file, use the name as shown on the claim. Suppress the “Ordered by” line if not able to identify the doctor. For carriers, if the ordering physician is the same as any performing physician on the claim, suppress the ordering physician line. If the NPI submitted on the claim is not on the contractor’s file, suppress the “Ordered by” line.

CONTENT

{Date(s) of Service}

{Supplier Name}, {10-digit phone number for supplier}

{Supplier Street Address}{Supplier State}{Supplier ZIP+4}

Ordered by {Provider Title} {Provider Given Name}{Provider Middle Initial}{Provider Family Name}

D. Claim Column Titles

The language used for the column headers differs for each member of the extended family of MSNs. See the specific content specifications below for details.

PART A INPATIENT SPECIFICATIONS

POSITION/FORMATTING

This subsection is directly after the claims header subsection. It is full-page or 540 points in width and 42.25 points in height. Content should have 5 points of space from top and 7 points of space from the bottom. There are seven columns with varying widths. All content is to be bottom aligned. See figure 10.3.6.D1 and Exhibit 1.1 for reference.

Listed below are widths and formatting for each column:

Column 1: 188 points wide, no content

Column 2: 42 points wide, [TH 5.1] right aligned

Column 3: 62 points wide, [TH 5.1] right aligned

Column 4: 66 points wide, [TH 5.1] right aligned

Column 5: 71 points wide, [TH 5.1] right aligned with 5 point indent

Column 6: 73 points wide, [TH 5.2] right aligned with 3.5 point intent, white text on black fill and [GR 2.2] on both sides of the column

Column 7: 38 points wide, [TH 5.1] left aligned with 5 point indent

DYNAMIC RULES

n/a – the content in this subsection is static.

CONTENT

(blank)

Benefit Days Used

Claim Approved?

Non-Covered Charges

Amount Medicare Paid

Maximum You May Be Billed

See Notes Below

HOSPICE AND HOME HEALTH SPECIFICATIONS

POSITION/FORMATTING

This subsection is directly after the claims header subsection. It is full-page or 540 points in width and 42.25 points in height. Content should have 5 points of space from the top and 7 points of space from the bottom. There are seven columns with varying widths. All content is to be bottom aligned. See figure 10.3.6.D2, Exhibit 1.3, and Exhibit 1.4 for reference.

Listed below are widths and formatting for each column:

Column 1: 174 points wide, [TH 5.1] left aligned

Column 2: 52 points wide, [TH 5.1] right aligned

Column 3: 66 points wide, [TH 5.1] right aligned

Column 4: 66 points wide, [TH 5.1] right aligned

Column 5: 71 points wide, [TH 5.1] right aligned with 5 point indent

Column 6: 73 points wide, [TH 5.2] right aligned with 3.5 point intent, white text on black fill and [GR 2.2] on both sides of the column

Column 7: 38 points wide, [TH 5.1] left aligned with 5 point indent

DYNAMIC RULES

The content in this subsection is static.

CONTENT

Quantity & Service Provided

Service Approved?

Amount Provider Charged

Medicare-Approved Amount

Amount Medicare Paid

Maximum You May Be Billed

See Notes Below

PART B ASSIGNED SPECIFICATIONS

POSITION/FORMATTING

This subsection is directly after the claims header subsection. It is full-page or 540 points in width and 42.25 points in height. Content should have 5 points of space from the top and 7 points of space from the bottom. There are seven columns with varying widths. All content is to be bottom aligned. See figure 10.3.6.D2, Exhibit 1.5 for reference.

Listed below are widths and formatting for each column:

Column 1: 174 points wide, [TH 5.1] left aligned

Column 2: 52 points wide, [TH 5.1] right aligned

Column 3: 66 points wide, [TH 5.1] right aligned

Column 4: 66 points wide, [TH 5.1] right aligned

Column 5: 71 points wide, [TH 5.1] right aligned with 5 point indent

Column 6: 73 points wide, [TH 5.2] right aligned with 3.5 point intent, white text on black fill and [GR 2.2] on both sides of the column

Column 7: 38 points wide, [TH 5.1] left aligned with 5 point indent

DYNAMIC RULES

The content in this subsection is static.

CONTENT

Service Provided & Billing Code

Service Approved?

Amount Provider Charged

Medicare-Approved Amount

Amount Medicare Paid

Maximum You May Be Billed

See Notes Below

PART B UNASSIGNED SPECIFICATIONS

POSITION/FORMATTING

This subsection is directly after the claims header subsection. It is full-page or 540 points in width and 42.25 points in height. Content should have 5 points of space from the top and 7 points of space from the bottom. There are seven columns with varying widths. All content is to be bottom aligned. See figure 10.3.6.D2 and Exhibit 1.6 for reference.

Listed below are widths and formatting for each column:

Column 1: 174 points wide, [TH 5.1] left aligned

Column 2: 52 points wide, [TH 5.1] right aligned

Column 3: 66 points wide, [TH 5.1] right aligned

Column 4: 66 points wide, [TH 5.1] right aligned

Column 5: 71 points wide, [TH 5.1] right aligned with 5 point indent

Column 6: 73 points wide, [TH 5.2] right aligned with 3.5 point intent, white text on black fill and [GR 2.2] on both sides of the column

Column 7: 38 points wide, [TH 5.1] left aligned with 5 point indent

DYNAMIC RULES

n/a – the content in this subsection is static.

CONTENT

Service Provided & Billing Code

Service Approved?

Amount Provider Charged

Medicare-Approved Amount

Medicare Paid You

Maximum You May Be Billed

See Notes Below

‘B OF A’ SPECIFICATIONS

POSITION/FORMATTING

This subsection is directly after the claims header subsection. It is full-page or 540 points in width and 42.25 points in height. Content should have 5 points of space from the top and 7 points of space from the bottom. There are seven columns with varying widths. All content is to be bottom aligned. See figure 10.3.6.D2 and Exhibit 1.2 for reference.

Listed below are widths and formatting for each column:

Column 1: 174 points wide, [TH 5.1] left aligned

Column 2: 52 points wide, [TH 5.1] right aligned

Column 3: 66 points wide, [TH 5.1] right aligned

Column 4: 66 points wide, [TH 5.1] right aligned

Column 5: 71 points wide, [TH 5.1] right aligned with 5 point indent

Column 6: 73 points wide, [TH 5.2] right aligned with 3.5 point intent, white text on black fill and [GR 2.2] on both sides of the column

Column 7: 38 points wide, [TH 5.1] left aligned with 5 point indent

DYNAMIC RULES

n/a – the content in this subsection is static.

CONTENT

Service Provided & Billing Code

Service Approved?

Amount Facility Charged

Medicare-Approved Amount

Amount Medicare Paid

Maximum You May Be Billed

See Notes Below

DME ASSIGNED SPECIFICATIONS

POSITION/FORMATTING

This subsection is directly after the claims header subsection. It is full-page or 540 points in width and 42.25 points in height. Content should have 5 points of space from the top and 7 points of space from the bottom. There are seven columns with varying widths. All content is to be bottom aligned. See figure 10.3.6.D2 and Exhibit 1.7 for reference.

Listed below are widths and formatting for each column:

Column 1: 174 points wide, [TH 5.1] left aligned

Column 2: 52 points wide, [TH 5.1] right aligned

Column 3: 66 points wide, [TH 5.1] right aligned

Column 4: 66 points wide, [TH 5.1] right aligned

Column 5: 71 points wide, [TH 5.1] right aligned with 5 point indent

Column 6: 73 points wide, [TH 5.2] right aligned with 3.5 point intent, white text on black fill and [GR 2.2] on both sides of the column

Column 7: 38 points wide, [TH 5.1] left aligned with 5 point indent

DYNAMIC RULES

n/a – the content in this subsection is static.

CONTENT

Quantity, Item/Service Provided & Billing Code

Item/Service Approved?

Amount Supplier Charged

Medicare-Approved Amount

Amount Medicare Paid

Maximum You May Be Billed

See Notes Below

DME UNASSIGNED SPECIFICATIONS

POSITION/FORMATTING

This subsection is directly after the claims header subsection. It is full-page or 540 points in width and 42.25 points in height. Content should have 5 points of space from the top and 7 points of space from the bottom. There are seven columns with varying widths. All content is to be bottom aligned. See figure 10.3.6.D2 and Exhibit 1.8 for reference.

Listed below are widths and formatting for each column:

Column 1: 174 points wide, [TH 5.1] left aligned

Column 2: 52 points wide, [TH 5.1] right aligned

Column 3: 66 points wide, [TH 5.1] right aligned

Column 4: 66 points wide, [TH 5.1] right aligned

Column 5: 71 points wide, [TH 5.1] right aligned with 5 point indent

Column 6: 73 points wide, [TH 5.2] right aligned with 3.5 point intent, white text on black fill and [GR 2.2] on both sides of the column

Column 7: 38 points wide, [TH 5.1] left aligned with 5 point indent

DYNAMIC RULES

n/a – the content in this subsection is static.

CONTENT

Quantity, Item/Service Provided & Billing Code

Item/Service Approved?

Amount Provider Charged

Medicare-Approved Amount

Medicare Paid You

Maximum You May Be Billed

See Notes Below

E. Claim Content Lines

The content in the claim lines is beneficiary-specific and also differs for each member of the extended family of MSNs. See the specific content specifications below for details.

POSITION

This subsection is directly after the claim column titles subsection. It is full-page or 540 points in width and has a variable height, depending on the number of service line items in the given claims. There are seven columns, corresponding to the column titles subsection. All content is top aligned.

PART A INPATIENT SPECIFICATIONS

FORMATTING

[GR 3.2] dotted rule [GR 2.2] black rule

Column 1: [TB 2.1] benefit period, left aligned

Column 2: [TB 2.1] approved status, right aligned

Column 3: [TB 2.1] amount charged, right aligned

Column 4: [TB 2.1] amount approved t, right aligned

Column 5: [TB 2.1] amount paid, right aligned, with 5 point indent

Column 6: [TB 2.2] maximum, right aligned, with 3.5 point indent

Column 7: [TB 2.2] note indicator, left aligned, with 5 point indent

NOTE: When there is more than one service line, start with [GR 3.2] dotted rule to allow distinction between the services by the dotted rule.

The first line of column 6 will have [GR 2.2] on top and sides of the column. Subsequent lines will have [GR 2.2] on the sides only.

DYNAMIC RULES

The content in this section is nearly entirely dynamically generated. It includes the following content elements:

Description of Part A Inpatient Service

This column should contain the associated benefit-period start date. Language options include:

Benefit period starting {Month DD, YYYY}

The date of service is listed with a spelled-out month, numeric day, and complete numeric year (e.g., October 15, 2021).

If there is no active benefit period because the claims are rejected, leave this field blank.

Benefit Days Used

This column shows the number of benefit days used during the hospital or skilled nursing facility admission, it indicates that a claim did not use benefit days because all the beneficiary’s benefit days for the given period have been exhausted, or there was no active benefit period because the claim was rejected. Language options include:

1 day

{#} days

none remain

none

See Exhibit 2.7 for an example of the “none remain” option.

Claim Approved?

This column indicates if a claim item was approved or denied. It also indicates if a claim was adjusted. Language options include:

Yes

NO

Yes – adjusted

NO – adjusted

See Exhibit 2.8 for an example of an adjusted claim (this example shows a Part B MSN, but it can be understood to also apply to other members of the extended family).

Non-Covered Charges

This column lists the amount of any claim charges that Medicare did not cover. Noncovered services will include beneficiary-liable as well as provider-liable charges. This figure may be up to eight digits long, including cents:

${###,###.##}

Insert a comma between the thousands’ digit and the hundreds’ digit of any four-figure or higher amount. Use $0.00 for zero.

Amount Medicare Paid

This column lists the amount that Medicare paid toward the claim. This figure may be up to eight digits long, including cents:

${###,###.##}

Insert a comma between the thousands’ digit and the hundreds’ digit of any four-figure or higher amount. Use $0.00 for zero.

Maximum You May Be Billed

This column lists the beneficiary’s total liability for the claim item. This figure may be up to eight digits long, including cents:

${###,###.##}

Insert a comma between the thousands’ digit and the hundreds’ digit of any four-figure or higher amount. Use $0.00 for zero.

See Notes Below

This column displays indicators that refer to explanations listed in the Notes for Claims Above subsection, which is printed at the bottom of the page when applicable.

Note indicators use capital letters, and indicators should be printed in alphabetic order, with a comma without space preceding each indicator after the first indicator for a line (e.g., A,B,C). Show no more than three alphabetic indicators per line. If more than three indicators are required, print on the next line below. A maximum of five notes are allowed per service, so no more than five note indicators should ever be listed here.

If the same message is needed for more than one claim or service line on a single page, print the same alphabetic code each time the message is required on that page. If, however, that same message is required on a following page, use a new indicator letter in the appropriate alphabetical order for that page.

Continue alphabetical order from page to page – do not restart the alphabet on each new page.

If more than 26 alphabetic codes are needed, begin using lowercase alphabetic codes (e.g., a,b,c). If more than 52 alphabetic codes are needed, repeat using capital letters.

CONTENT

{Inpatient hospital benefit period starting Month DD, YYYY} [or] {Skilled nursing facility benefit period starting Month DD, YYYY}

1 day [or] {#} days [or] none remain

Yes [or] NO [or] Yes – adjusted [or] NO – adjusted

${###,###.##}

${###,###.##}

${###,###.##}

{NOTE INDICATOR(S)}

or

[blank]

none

Yes [or] NO [or] Yes – adjusted [or] NO – adjusted

${###,###.##}

${###,###.##}

${###,###.##}

{NOTE INDICATOR(S)}

HOSPICE SPECIFICATIONS

See Exhibit 1.3 for layout reference.

[The below figure has been revised.]

FORMATTING

[GR 3.2] dotted line [GR 2.2] black rule

Column 1: [TB 2.2] quantity and level of care description, left aligned or [TB 2.] quantity and service visit description, left aligned

Column 2: [TB 2.1] approved status for level of care, right aligned

Column 3: [TB 2.1] amount charged for level of care, right aligned

Column 4: [TB 2.1] amount approved for level of care, right aligned

Column 5: [TB 2.1] amount paid for level of care, right aligned, with 5 point indent

Column 6: [TB 2.2] maximum for level of care, right aligned, with 3.5 point indent

Column 7: [TB 2.2] note indicator for level of care, left aligned, with 5 point indent

NOTE: Columns 2 through 7 should be filled only for level of care. They should be left blank for service visit lines.

The first line of column 6 will have [GR 2.2] on top and sides of the column. Subsequent lines will have [GR 2.2] on the sides only.

NOTE: Between level of care and service visit lines, insert [GR 5] 7 point space in between the claim lines. There is no dotted line in between.

DYNAMIC RULES

The content in this section is entirely dynamically generated. It includes the following content elements:

Quantity & Service Provided

This column should contain the quantity or number of level of care provided, followed by the description of the level of care provided in bold. Then items below should contain the quantity or number of service visit provided, followed by the description of the service visit provided. There may be multiple service visit types per one level of care.

Whenever possible, the number of level of care and service visit provided should be expressed as a whole number, without decimal point or trailing zero (e.g. 2, not 2.0). Only if the number is a partial quantity, then include a decimal point and a fractional amount, rounded to the nearest tenth (e.g. 2.5, not 2.49). Use the most-recent level of care and service visit descriptions. Suppress the billing code.

Service Approved?

This column indicates if a claim item was approved or denied. It also indicates if a claim was adjusted. Language options include:

Yes

NO

Yes – adjusted

NO – adjusted

See Exhibit 2.8 for an example of an adjusted claim.

Amount Provider Charged

This column lists the amount of the charge the provider submitted. This figure field has a maximum of 11 characters, including cents:

${###,###.##}

Insert a comma between the thousands’ digit and the hundreds’ digit of any four-figure or higher amount. Use $0.00 for zero.

Medicare-Approved Amount

This column lists the amount that Medicare allows for the service. This field has a maximum of 11 characters, including cents:

${###,###.##}

Insert a comma between the thousands’ digit and the hundreds’ digit of any four-figure or higher amount. Use $0.00 for zero.

Amount Medicare Paid

This column lists the amount that Medicare paid toward the claim. This field has a maximum of 11 characters, including cents:

${###,###.##}

Insert a comma between the thousands’ digit and the hundreds’ digit of any four-figure or higher amount. Use $0.00 for zero.

Maximum You May Be Billed

This column lists the beneficiary’s total liability for the claim item. This field has a maximum of 11 characters, including cents:

${###,###.##}

Insert a comma between the thousands’ digit and the hundreds’ digit of any four-figure or higher amount. Use $0.00 for zero.

See Notes Below

This column displays indicators that refer to explanations listed in the “Notes for Claims Above” subsection, which is printed at the bottom of the page when applicable.

Note indicators use capital letters, and indicators should be printed in alphabetic order, with a comma without space preceding each indicator after the first indicator for a line (e.g., A,B,C). Show no more than three alphabetic indicators per line. If more than three indicators are required, print on the next line below. A maximum of six notes are allowed per service, so no more than six note indicators should ever be listed here.

If the same message is needed for more than one claim or service line on a single page, print the same alphabetic code each time the message is required on that page. If, however, that same message is required on a following page, use a new indicator letter in the appropriate alphabetical order for that page.

Continue alphabetical order from page to page – do not restart the alphabet on each new page.

If more than 26 alphabetic codes are needed, begin using lowercase alphabetic codes (e.g., a,b,c). If more than 52 alphabetic codes are needed, repeat using capital letters.

CONTENT

{Level of care description} {Service visit description} Yes [or] NO [or] Yes – adjusted [or] NO – adjusted ${###,###.##} ${###,###.##} ${###,###.##} ${###,###.##} {NOTE INDICATOR(S)} HOME HEALTH SPECIFICATIONS

MSN - Specifications for Section 3: Claims (Rev. 3210, 04-16-15). (2015, August 10). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/msn-specifications-for-section-3-claims-rev-3210-04-16-15-26787.html

© InnoviHealth Systems Inc

Article Tags  (click on a tag to see related articles)


Publish this Article on your Website, Blog or Newsletter

This article is available for publishing on websites, blogs, and newsletters. The article must be published in its entirety - all links must be active. If you would like to publish this article, please contact us and let us know where you will be publishing it. The easiest way to get the text of the article is to highlight and copy. Or use your browser's "View Source" option to capture the HTML formatted code.

If you would like a specific article written on a medical coding and billing topic, please Contact Us.


contact

innoviHealth Systems, Inc.
62 East 300 North
Spanish Fork, UT 84660
Phone: 801-770-4203 (9-5 Mountain)
Email:
free demo
request yours today
pricing
for any budget
sign IN
welcome back!

Thank you for choosing Find-A-Code, please Sign In to remove ads.