(Medicare Claims Processing Manual)

PART B ASSIGNED SPEC IFICATIONS   See Figure 10.3.6.F2 and Exhibit 1.5 for layout reference.   FORMATTING   [GR 3.2] dotted rule [GR 2.2] black rule  Columns 1 -2: [TB 2.2] claim number, left aligned  Column 3:  [TB 2.1] amount charged total, right aligned  Column 4:  [TB 2.1] approved total, rig ht aligned  Column 5:  [TB 2.1] amount paid total, right aligned, with 5 point indent  Column 6:  [TB 2.2] maximum total, right aligned, with 3.5 point indent  Column 7:  [TB 2.2] note indicator, left aligned, with 5 point indent   NOTE:  The first line of column 6 will have [GR 2.2] on top, bottom, and both sides of the column as a highlight.  DYNAMIC RULES   The content in this section is nearly entirely dynamically generated.  It includes the following content elements:   Claim Number   This column lists the claim number for the claim, preceded by a static text phrase:   Total for Claim #{Claim Number}   Insert dashes in the claim number as indicated by the system.   Total Amount Provider Charged   This column lists the sum of the line -item amo unts above of the charges 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.   Total Medicare- Approved Amount   This column lists the sum of the line -items amounts above for what 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.   Total Amount Medicare Paid   This column lists the sum of the line -item amounts above for what 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.   Total Maximum You May Be Billed   This column lists the sum of the line -item amounts above showing the beneficiarys 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.  See the description in the Claim Content Lines specifications for detailed instructions.  A maximum of six notes are allowed per total line.   CONTENT   Total for Claim #{Claim Number}  ${###,###.##} ${###,###.##} ${###,###.##} ${###,###.##}  {NOTE INDICATOR(S)}   PART B UNASSIGNED SPECIFICATIONS   See figure 10.3.6.F2 or Exhibit  1.6 for layout reference.   FORMATTING   [GR 3.2] dotted rule [GR 2.2] black rule  Columns 1 -2: [TB 2.2] claim number, left aligned  Column 3:  [TB 2.1] amount charged total, right aligned  Column 4:  [TB 2.1] approved total, right aligned  Column 5:  [TB 2.1] amount paid total, right aligned, with 5 point indent  Column 6:  [TB 2.2] maximum total, right aligned, with 3.5 point indent  Column 7:  [TB 2.2] note indicator, left aligned, with 5 point indent   NOTE:  The first line of column 6 will have [GR 2.2] on top, bottom, and both sides of the column as a highlight.  DYNAMIC RULES   The content in this section is nearly entirely dynamically generated.  It includes the following content elements:   Claim Number   This column lists the claim number for the claim, preceded by a static text phrase:   Total for Claim #{Claim Number}   Insert dashes in the claim number as indicated by the system.   Total Amount Provider Charged   This column lists the sum of the line -item a mounts above of the charges 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.   Total Medicare- Approved Amount   This column lists the sum of the line -items amounts above for what 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.   Total Amount Medicare Paid You   This column lists the sum of the line -item amounts above for what Medicare paid the beneficiary toward the claim.  This figure may be up to eig ht 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.   Total Maximum You May Be Billed   This column lists the sum of the line -item amounts above showing the beneficiarys 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.  Us e $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.  See the description in the Claim Content Lines specifications for detailed instructions.  A maximum of six notes are allowed per total line.   CONTENT   Total for Claim #{Claim Number}  ${###,###.##} ${###,###.##} ${###,###.##} ${###,###.##}  {NOTE INDICATOR(S)}   B OF A  SPECIFICATIONS   See Exhibit 1.2 for layout reference.     FORMATTING   [GR 3.2] dotted rule [GR 2.2] black rule  Columns 1 -2: [TB 2.2] claim number, left aligned  Column 3:  [TB 2.1] amount charged total, right aligned  Column 4:  [TB 2.1] approved total, right aligned  Column 5:  [TB 2.1] amount paid total, right aligned, with 5 point indent  Column 6:  [TB 2.2] maximum total, right aligned, with 3.5 point indent  Column 7:  [TB 2.2] note indicator, left aligned, with 5 point indent   NOTE:  The first line of column 6 will have [GR 2.2]  on top, bottom, and both sides of the column as a highlight.  DYNAMIC RULES   The content in this section is nearly entirely dynamically generated.  It includes the following content elements:   Claim Number   This column lists the claim number for the claim, preceded by a static text phrase:   Total for Claim #{Claim Number}   Insert dashes in the claim number as indicated by the system.   Total Amount Facility Charged   This column lists the sum of the line -item amounts above of the charges the facility 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.  If the field has more than 11 characters, replace with see note and list the amount in the notes.  Total Medicare- Approved Amount   This column lists the sum of the line -items amounts above for what 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.  If the field has more than 11 characters, replace with see note and list the amount in the notes.  Total Amount Medicare Paid   This column lists the sum of the line -item amounts above for what 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 dig it of any four -figure or higher amount.  Use $0.00 for zero.  If the field has more than 11 characters, replace with see note and list the amount in the notes.  Total Maximum You May Be Billed   This column lists the sum of the line -item amounts above showing the beneficiarys 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.  If the field has more than 11 characters, replace with see note and list the amount in the notes.  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.  See the description in the Claim Content Lines specifications for detailed instructions.  A maximum of six notes are allowed per total line.   CONTENT   Total for Claim #{Claim Number}   ${###,###.##} ${###,###.##} ${###,###.##} ${###,###.##}  {NOTE INDICATOR(S)}   DME ASSIGNED SPECIFI CATIONS   See figure 10.3.6.F3 or Exhibit 1.7 for layout reference.   FORMATTING   [GR 3.2] dotted rule [GR 2.2] black rule  Columns 1 -2: [TB 2.2] claim number, left aligned  Column 3:  [TB 2.1] amount charged total, right aligned  Column 4:  [TB 2.1] approved total, right aligned  Column 5:  [TB 2.1] amount paid total, right aligned, with 5 point indent  Column 6:  [TB 2.2] maximum total, right aligned, with 3.5 point indent  Column 7:  [TB 2.2] note indicator, left aligned, with 5 point indent   NOTE:  The first line of column 6 will have [GR 2.2] on top, bottom, and both sides of the column as a highlight.  DYNAMIC RULES   The content in this section is nearly entirely dynamically generated.  It includes the following content elements:   Claim Number   This column lists the claim number for the claim, preceded by a static text phrase:   Total for Claim #{Claim Number}   Insert dashes in the claim number as indicated by the system.   Total Amount Suppli er Charged   This column lists the sum of the line -item amounts above of the charges the supplier 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.   Total Medicare- Approved Amount   This column lists the sum of the line -items amounts above for what Medicare allows for the item or 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.   Total Amount Medicare Paid   This column lists the sum of the line -item amounts above for what 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.   Total Maximum You May Be Billed