(Medicare Claims Processing Manual)

Medicare -Approved Amount   This column lists the amount that Medicare allows for th e service.  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.   Max imum You May Be Billed   This column lists the beneficiarys 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 capit al 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 t he 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   {Service description} ({Revenue Code})  Yes [or] NO [or] Yes -  adjusted [or]  NO - adjusted  ${###,###.##} ${###,###.##} ${###,###.##} ${###,###.##}  {NOTE INDICATOR(S)}   DME ASSIGNED SPECIFI CATIONS   See Exhibit 1.7 for layout reference.   FORMATTING   [GR 3.2] dotted line [GR 2.2] black rule  Column 1:  [TB 2.1] quantity and item/service description, 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, 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   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:  When there is more than one service line, insert [GR 5] 7 point space in between the claim lines.  There is no dotted line in between.   NOTE:  For multiple dates subtitle, insert the  following before corresponding service lines(s):   [TH 5.1] date or provider information [GR 5] space after   See Exhibit 2.6 for examples of claims with these various options for dynamic column subtitles.   DYNAMIC RULES   The content in this section is entirely dynamically generated.  It includes the following content elements:   Quantity, Item/Service Provided & Billing Code   This column should contain the quantity or number of services provided, the description of the service provided and, in parenthese s, the billing code for that service, followed by any modifier code and modifier descriptor.  Whenever possible, the number of services 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 consumer -friendly HCPCS (level 1)/CPT service descriptions, which can be found on the CMS systems mai nframe or at https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html .  The service description has a maximum of 100 characters.  Suppress the rest if the description runs  longer.   Item/Service Approved?   This column indicates if a claim item or service 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).   Amount Provider Charged   This column lists the amount of the charge the provider submitted.  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.   Medicare -Approved Amount   This column lists the amount that Medicare allows for the  service.  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.   Maxi mum You May Be Billed   The first line of claim will have [GR 2.2] on top and sides of the column.  Subsequent lines will have [GR 2.2] on the sides only.   This column lists the beneficiarys 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 l isted 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 afte r 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 i ndicators 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 f ollowing 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 lowercas e alphabetic codes (e.g., a,b,c). If more than 52 alphabetic codes are needed, repeat using capital letters.   Multiple Dates Subtitles   If a single claim includes services provided on multiple dates, then a dynamic date subtitle should be introduced into the claim body, separating the individual claim items into clusters by date.  See Exhibit 2.6 for examples of claims with these various options for dynamic column subtitles.  Any subtitle should run across the full width of the claim columns, but the dynam ic content is placed only in the first column.  The preference is for each individual day to be given a separate subtitle, with claim items grouped just by that one date.  The date subtitle clusters should then be listed chronologically, earliest first.  I f the claims data for an item only includes a range, then that claim item can be listed under a range header, which should be sorted chronologically by its start date.  The date format follows the same conventions outlined above in the Claim Header subsect ion.  CONTENT   {Item or Service description} ({Revenue Code})  Yes [or] NO [or] Yes -  adjusted [or]  NO - adjusted  ${###,###.##} ${###,###.##} ${###,###.##} ${###,###.##}  {NOTE INDICATOR(S)}   DME UNASSIGNED SPECI FICATIONS   See Exhibit 1.8 for layout reference.   FORMATTING   [GR 3.2] dotted line [GR 2.2] black rule  Column 1:  [TB 2.1] quantity and item/service description, 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] am ount approved, 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   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:  When there is more than one service line, insert [GR 5] 7 point space in between the claim lines.  There is no dotted line in between.   NOTE : For multiple dates subtitle, insert the following before corresponding service lines(s):   [TH 5.1] date or provider information [GR 5] space after   See Exhibit 2.6 for examples of claims with these various options for dynamic column subtitles.   DYNAMIC RULES   The content in this section is entirely dynamically generated. It includes the following content elements:   Quantity, Item/Service Provided & Billing Code   This column should contain the quantity or number of services provided, the description of the service provided and, in parentheses, the billing code for that service, followed by any modifier code and modifier descriptor.  Whenever possible, the number of services provided should be expressed as a whole number, without decimal point or trailing z ero (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 consumer -friendly HCPCS (level 1)/CPT service descriptions, the long descriptions for level 2, which can be found on the CMS systems mainframe or at https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html .  The service description has a maximum of 100 characters.  Suppress the rest if the description runs longer.   Item/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 (this example shows a Part B MSN, but it can be understood to also apply to other members of the ex tended family).   Amount Provider Charged   This column lists the amount of the charge the provider submitted.  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.   Medicare -Approved Amount   This column lists the amount that Medicare allows for the service.  This figure may be up to eight digits long, including cents:   ${###,###.##}