(Medicare Claims Processing Manual)

HOSPICE SPECIFICATIO NS  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.   Defin itions of Columns   Service Approved?: This column tells you if Medicare covered the hospice service.   Amount Provider Charged: This is your providers 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 amou nt 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 SPECIFIC ATIONS   CONTENT   Part A Hospital Insuran ce 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 providers 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 Yo u 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 insur ance, it may pay all or part of this amount.   PART B ASSIGNED SPEC IFICATIONS   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 providers 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.  T his 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 Insuran ce (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 hasnt agreed to accept the Me dicare- approved amount as payment in full.  Do Unassigned Claims Cost More? Maybe. A provider who doesnt 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 providers fee for this service.   Medicare -Approved Amount : This is the amount a provider can be paid for a Medicare service. S ince your provider hasnt 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 doesnt accept assignment, Medicare pays you directly.  Youll 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 Supp lement 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 dep artments, 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 facilitys 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 c an 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 SPECIFI CATIONS   CONTENT   Part B Medical Insurance help s 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 suppliers 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 SPECI FICA TIONS   CONTENT   Medicare claims may be assigned or unassigned.  Your claims below are unassigned  - meaning the supplier hasnt agreed to accept the Medicare- approved amount as payment in full.  Do Unassigned Claims Cost More? Maybe. A supplier who doesnt 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 Medicare-covered services and doesnt 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 suppliers 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 hasnt agreed to accept assignment, you might be charged more than this amount (see Do Unassigned Claims Cost More to y our left).  Medicare usually pays 80% of the Medicare -approved amount.  Medicare Paid You : When a supplier doesnt accept assignment, Medicare pays you directly.  Youll 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 i nformation about Medicare assignment, see your Medicare & You handbook.  C. Claim Header   GLOBAL SPECIFICATION S  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, rathe r 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. terr itories.  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, HO SPICE, HOME HEALTH AND B OF A  SPECIFICATIONS   FORMATTING   [GR 1] gray fill  [GR 2.1] black rule  [TH 4] Claim Service Date  [GR 5] space after text  [TB 2.2] facility/provider name and telephone number  [TB 2.1] facility/provider addres s  [TB 2.1] referring provider   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 providers 10- digit phone number, preceded by a comma to separate it from th e facility or provider name.  Enclose the area code within parentheses.  Insert a dash between the third and fourth digit of the local phone number.