(Medicare Claims Processing Manual)

Medicare Claims Processing Manual  Chapter 21 - Medicare Summary Notices   Table of Contents  (Rev. 11509, 07- 28-22) (Rev. 11510, 07- 28-22)    Transmittals for Chapter 21  10 - General Medicare Summary Notices (MSN) Requirements  10.1 -  General Requirements for the MSN  10.2 -  Correction/Reissuance of Faulty MSNs  10.3 -  A/B MAC (A), (B), (HHH), and DME MAC  Instructions for Preparing the MSN  10.3.1 -  Basic Concepts and Approaches  10.3.2 -  Format Conventions for the MSN  10.3.3 -  Specifications for Sectio n 1: Summary (Page 1)  10.3.4 -  Specifications for Header for Other Pages  10.3.5 -  Specifications for Section 2: Making the Most of Your Medicare (Page 2)  10.3.6 -  Specifi cations for Section 3: Claims  10.3.7 -  Claims Calculations  10.3.8 -  Specifications for Section 4 (Last Page): Denials and Appeals  10.3.9 -  Specifications for Pay MSN  Cover Sheet & Check  10.3.10 -  Specifications for Envelopes  10.3.11 -  Specifications for RRB Part B MSNs  10.3.12 -  Specifications for SSA Part B MSNs  10.3.13 -  Character Measurements for Fonts  20 - Specifications for Spanish MSN  20.1 -  Specifications for Content Variation of Spanish MSNs  30 - Exhibits  30.1 -  Exhibits of the Extended Family of MSNs in Black and White  30.2 -  Exhibits of Alternate Scenarios  30.3 -  Exhibits of MSNs in Spanish 30.4 -  Exhibits of the Extended Family of MSNs in Color  40 - General Information, Explanatory, and Denia l Messages  10 - General Medicare Summary Notices (MSN) Requirements  (Rev. 955, Issued: 05- 19-06, Effective: MCS -June 12, 2006, VMS -July 1, 2006, FISS -September 1, 2006, Implementation: MCS -June 12, 2006, VMS -July 3, 2006, FISS -September 1, 2006)   Effectiv e July 1, 2002, the MSN is used by all A/B MACs (A), (B), (HHH), and DME MACs.   The MSN is the primary vehicle by which beneficiaries are notified of decisions on their claims for Medicare benefits.  The A/B MAC (A), (B), (HHH), or DME MAC mails a single M SN at the end of the month to each beneficiary for whom claim was processed during the month to inform the beneficiary of the disposition of all claims.  All MACs  shall issue No -Pay MSNs on a quarterly/90 day mailing cycle.  MSNs with checks to the beneficiary will continue to be mailed out as processed.  To ensure that all messages are uniform throughout the Medicare program, A/B MACs (A), (B), (HHH), and DME MACs may not use locally developed MSN messages until approved by the regional office (RO).   The MSNs are not sent to providers.  Providers receive remittance advice records.  (See Chapter 22 for instructions about the provider remittance record.)   The MSN contains the following sections or areas:    Disclaimer;   Title;  Claims Information;   Message; and   Appeals.   Detailed requirements for completion of each section are included in 10.3.  Generally, A/B MAC (A), (B), (HHH), or DME MAC requirements are the same.  Where there are differences or where the specific specification applies to only the A/B MAC (B)/DME MAC or to only the A/B MAC (A)/(HHH), the difference is noted in the specific instruction.  Although every attempt has been made to make the MSN as simple as possible, the MSN is sufficiently complex that MACs must maintain continuing training efforts directed at beneficiaries and providers for understanding and interpretation of data on the MSN.  Although providers are not mailed copies of MSNs, beneficiaries frequently show MSNs to providers to establish deductible status for provider billing.   10.1 - General Requirements for the MSN  (Rev. 1491, Issued: 04- 11-08, Effective: 05- 12-08, Implementation: 05- 12-08)  A.  A/B MAC (A)/(HHH) MSN   The MSN is used to notify Medicare beneficiaries of action taken on A/B MAC (A)/(HHH) processed claims.  MSNs are not used by A/B MACs (HHH) for RAPs, and RAP data are not included on the monthly MSN.  The MSN provides the beneficiary with a record of services received and the status of any deductibles.  The MSN also informs the beneficiary of appeal rights.  The Balanced Budget Act of 1997 requires all Part A benefit notices to include the amount of Medicare payment for each service.  A/B M ACs (A) and (HHH), must furnish an MSN to all beneficiaries for whom claims are filed during the month unless the situation is specifically excluded by other manual instructions.  MACs  shall issue No -Pay MSNs on a quarterly/90 day mailing cycle.  MSNs with  a payment check to the beneficiary shall continue to be mailed out as processed.  No- pay MSNs are defined as those MSNs which do not require payment to the beneficiary for the respective claim(s).   The MSN replaced the following documents:    Form CMS -1533, Part A Medicare Benefit Notice, also known as the Part A Notice of Utilization (NOU) sent for inpatient services;   Form CMS -1954, Benefit Denial Letter (BDL), sent for partially denied claims; and    Form CMS -1955, BDL sent for totally denied claims.  Since CMS eliminated BDLs, Medicare beneficiaries receive the information previously conveyed on BDLs through narrative messages contained on the MSN.  Providers no longer receive a separate written notification or copy of the BDL.  Providers must utilize the coding information (e.g., ANSI Reason Codes) conveyed on the financial remittance advice to ascertain reasons associated with Medicare claims determinations affecting payment and applicable appeal rights and/or appeals information.  B.  A/B MAC (B)/DME MAC MSN   The MSN is used to notify Medicare beneficiaries of action taken on their processed claims.  The MSN provides the beneficiary with a record of services received and the status of any deductibles.  The MSN also informs the beneficiary of appeal rights .  10.2 - Correction/Reissuance of Faulty MSNs (Rev. 159, 04- 30-04)  Occasionally programming errors will occur which cause inaccuracies on MSNs that do not materially affect benefits.  An example of a potential programming error could be one data column w riting in another data column.  So long as the claims are correctly paid and the notice is intelligible, it is not necessary to identify the impacted MSNs or reissue them.  The resources to identify and reissue all of the documents would not be justified.  In situations where MACs feel reissuance is absolutely necessary, they must work with their regional office to identify costs involved before proceeding.  When such problems occur, MACs must take actions that will inform beneficiaries of the situation.  T hese actions should fall within the framework of routine operations.  Such actions include, but are not limited to, fielding calls from beneficiaries and alerting customer service representatives of the situation  and posting an alert on MACs Web sites.  W hile not all of these solutions may be possible, MACs should take the most appropriate steps to best mitigate the potential confusion, but not incur special costs.  Any communication regarding this type of situation should convey that it was a temporary pr ogramming error, which has been fixed, and is believed not to have affected the beneficiarys benefits.   A beneficiary may call the MAC to request a copy of the MSN with the correct information.  In such cases, the MAC will provide one.  10.3 - A/B MAC (A) , (B), (HHH), or DME MAC Instructions for Preparing the MSN  (Rev. 1, 10- 01-03) PM A -99-48  10.3.1 - Basic Concepts and Approaches  (Rev. 3210, Issued: 03- 03-15, Effective: 04- 16-15. Implementation: 04- 16-15)  A. Overview   The Medicare Summary Notice (MSN) is a  printed notification, sent to Medicare beneficiaries enrolled in Original Medicare, that displays data for claims processed during a given reporting period.  The MSN lists claim information in a summarized format.  It also contains other helpful infor mation for beneficiaries.  Each MSN consists of the following four sections:   SECTION 1: SUMMARY (PAGE 1)  A one -page summary of the beneficiarys Medicare status and of the claims data on the notice.   SECTION 2: MAKING THE MOST OF YOUR MEDICARE (PAGE 2)  One page with tips for beneficiaries on how to use their MSN, get help with Medicare issues, and learn more about Medicare services.   SECTION 3: CLAIMS (PAGE 3 -  X) A section, which may extend over multiple pages, listing the beneficiary claims submitted to  Medicare over the period of the notice.   SECTION 4: DENIALS & APPEALS (LAST PAGE)  One page containing details on beneficiaries appeals rights and, more generally, on how they can get help with denied claims.   Layout and content specifications for these s ections begin at 10.3.4.  Specifications address the position, formatting, content, and (if applicable) rules for dynamic content in individual subsections of each section.  B. Claim Types: The Extended Family of MSNs   Medicare claims are processed and paid under a range of different systems.  (In addition, different claim types may be processed and printed by separate MACs.)  While the overall appearance and format of all MSNs is consistent, different claim types do require some variations in the notice , in both the type of content supplied and the specific language used.   This document identifies eight  primary claim types  in the extended family of MSNs:   GLOBAL NOTICE:  This file version does not include specifications for Part A claims for inpatient mental health care in a psychiatric hospital.  The instructions for these claims will be included in a subsequent version.    Part A Inpatient  Claims for inpatient hospital services and skilled -nursing facility services.    B of A Claims for outpatient services provided by medical facilities; these claims are paid under the Part B program, but their claim data is presented in a format similar to Part A Inpatient claims.    Hospice  Claims for hospice care, which are paid for under Part A but require a claim  format more similar to Part B claims.    Home Health  Claims for home -health services that are paid under Part A or Part B.  These MSNs also require a claim format more similar to Part B claims.    Part B, unassigned  Claims for Part B medical services from pro viders that do not accept Medicare assignment; payment for unassigned claims may be made directly to beneficiaries, which affects the format of claims data on the MSN.    DME, assigned  Claims for durable medical equipment (DME) and related services from suppliers that accept Medicare assignment.    DME, unassigned  Claims for DME from suppliers that do not accept Medicare assignment; payment for unassigned claims may be made directly to beneficiaries, which affects the format of claims data on the MSN.   COMBINED MSNs   In some instances, multiple claim types may be combined on a single MSN.  This most commonly occurs with Part A Inpatient and B of A claims, with Part B assigned and unassigned claims, and with DME assigned and unassigned claims.  Instructions related to combined MSNs will be found below in any section or subsection that is affected.   PAY MSNs   From time to time, beneficiaries may receive an MSN that includes a check, refunding an overpayment made (most often) for Part B services, either assigne d or unassigned.  Instructions related to Pay MSNs will be found below in any section or subsection that is affected.  Instructions for the check cover sheet are located near the rear of this chapter.  Instructions for Pay MSN envelopes are located in the Envelopes section. In addition, there are examples of complete Pay MSNs in the Exhibits section.   EFFECT OF CLAIM TYPES   In the specifications below, layout and content instructions can be assumed to be global -  that is, they apply to all MSNs, regardless of what types of claims appear on the notice.   However, there are particular sections and subsections of the MSN where the type of claims on the MSN determines not only what specific claim data is printed, but also affects the inclusion of other content and language across the notice.