(Medicare Claims Processing Manual)

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 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.   Medicare Paid You   This column lists the amount that Medicare paid the beneficiary toward the unassigned 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 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 capital letters, and indicators should be printed in alphabetic order, with a comma without space preceding each indicator aft er 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 lowercase alphabetic codes (e.g., a,b,c). If more than 52 alphabetic codes are needed, repeat using capital letters.   Multiple Dates and/or Providers Subtitles   If a single Part B claim includes serv ices provided on multiple dates, or provided by individually named providers, or both, then a dynamic date, provider, or date and provider subtitle should be introduced into the claim body, separating the individual claim items into clusters by date, provider, or date and provider.  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 dynamic content is placed only in the first column.  In the case of a dynamic date subtitle, 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.  If 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 subsection.   In the case of separate providers listed for individual items within a claim, each provider should be named in a different subtitle, with associated claim items for that provider grouped underneath.  The provider clusters should be listed alphabetically by provider last name or facility name.  The provider format follows the same conventions outlined above in the Claim Header subsection.   If a single claim includes items with both different dates and different clusters, the items should be grouped first by date , then by provider, with each listed on a separate line.   CONTENT   {Service description} ({Revenue Code})  Yes [or] NO [or] Yes -  adjusted [or]  NO - adjusted  ${###,###.##} ${###,###.##} ${###,###.##} ${###,###.##}  {NOTE INDICATOR(S)}   PART B ASSIGNED SPECIFICATIONS   See Exhibit 1.5 for layout reference.     FORMATTING   [GR 3.2] dotted line [GR 2.2] black rule  Column 1:  [TB 2.1] service description, left aligned Column 2:  [TB 2.1] approved status, right aligned Column 3:  [TB 2.1] amount charged, right a ligned  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, format [GR 3.3] dotted rule 3 in between the claim lines.   NOTE:  For multiple dates and/or providers subtitles, insert the following before corresponding service lines(s):   [TH 5.1] date or provider information [GR 3.3] dotted rule 3  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:   Service Provided & Billing Code  This column should contain the description of the service provided and, in parentheses, the billing code for that service, followed by any modifier code and modifier descriptor.   Use the most recent consumer -friendly HCPCS (level 1)/CPT service descriptions, 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.   For the revenue code, use standar d abbreviations provided by the National Uniform Billing Committee without changing the wording.   The revenue code may have up to four 2 -character modifier codes, followed by 2 modifier descriptors.  The modifier descriptors have a maximum of 30 character s.   If a procedure code modifier is present in any of the four modifier fields on the claim detail, the following Modifier Descriptors will print:  Modifier  English  Spanish 80, 81, 82 Assistant surgeon  Cirujano asistente  26 Professional charge  Cargo profesional  TC Technical charge  Cargo tcnico  RR Rental  Renta Modifier  English  Spanish NR Purchase  Compra  RP Replacement/repair  Reemplazo/arreglo  55 Care after operation  Cuidado despues de operacin  56 Care before operation  Cuidado antes de la operacin  MS Maintenance/service  Mantenimiento/servicio  SG Surgery Center fee  Cargo del centro de ciruga  NOTE : When a specialty 59 provider submits a claim with modifiers RP, NR, RR and SG the Modifier Descriptors on the Medicare Summary Notice will be suppressed as they are not applicable to the services provided.   Keep current practice of listing modifier code and modifier descriptors.   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 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 tha t 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 B e 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 capital letters, an d 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 alphab etic 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.   Multiple Dates and/or Providers Subtit les  If a single Part B claim includes services provided on multiple dates, or provided by individually named providers, or both, then a dynamic date, provider, or date and provider subtitle should be introduced into the claim body, separating the individual claim items into clusters by date, provider, or date and provider.  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 dynamic content is placed only in the first column.  In the case of a dynamic date subtitle, 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 ch ronologically, earliest first.  If 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 subsection.   In the case of separate providers listed for individual items within a claim, each provider should be named in a different subtitle, with associated claim items for that provider grouped underneath.  The provider clus ters should be listed alphabetically by provider last name or facility name.  The provider format follows the same conventions outlined above in the Claim Header subsection.   If a single claim includes items with both different dates and different clusters , the items should be grouped first by date, then by provider, with each listed on a separate line.   CONTENT   {Service description} ({Revenue Code})  Yes [or] NO [or] Yes -  adjusted  [or]  NO - adjusted  ${###,###.##} ${###,###.##} ${###,###.##} ${###,###.##}  {NOTE INDICATOR(S)}   PART B UNASSIGNED SPECIFICATIONS   See figure 10.3.6.E2 or Exhibit 1.7 for layout reference.   FORMATTING