(Medicare Claims Processing Manual)

 The beneficiary had exhausted all of their lifetime mental health care days, then this subsection should indi cate that all lifetime mental health care days have been used.   The beneficiary did not use any mental health care days because the claim was rejected.   The possible dynamic statements for inpatient lifetime reserve benefit days are as follows:   You have {#} out of 190 mental health care days  remaining.   or  You have used all of your 190 mental health care reserve days.   or  You didnt have an active benefit period.   SKILLED NURSING FACILITY DAYS   Content in the beneficiary -specific portion of this subsect ion is subject to the following variations:    If a claim on the notice is for a skilled nursing facility (SNF) stay, and    The benefit period associated with the claim was still active on the notice date of the MSN -  because fewer than 60 days had passed bet ween the last claimed date of stay in the benefit period and the notice date -  then this subsection should list how many covered benefit days remain in the benefit period; or    The benefit period associated with the claim is closed -  because more than 60 days had passed since the last claimed date of stay and the notice date -  then this subsection should indicate that the SNF benefit period has ended.    There is no benefit period associated with the claim because it was rejected, therefore no benefit days w ere used.   The possible dynamic statements for skilled nursing facility hospital days are as follows:   You have {#} out of 100 covered benefit days  remaining for the benefit period that began {Month DD, YYYY}.  or  You have used all of your 100 covered ben efit days for the benefit period that began {Month DD, YYYY}.   or  The benefit periods for all claims on this notice have ended.   or  You didnt have an active benefit period.   DYNAMIC RULES   In an open inpatient hospital or skilled nursing facility benefi t period, the number of remaining covered/reserve days should reflect the number of days that remained on the notice date. If the beneficiary had no remaining benefit days on that date, but the period was still open, then the second inpatient/SNF statement  above should be used, indicating that all benefit days have been used for the period beginning on the stated date.   Only one active benefit period related to the claims listed on the statement should be printed. If there are any additional claims that pertain to another benefit period, suppress the status.   If claims on the notice use any combination of inpatient hospital days, inpatient lifetime reserve days, inpatient mental health care days or skilled nursing facility (SNF) days, then all of the appl icable statements, as described above, should be included in this subsection.  If claims did not use lifetime reserve days or inpatient mental health care days, suppress this section and list skilled nursing facility benefit period immediately after inpatient hospital.  CONTENT   Static content, and sample dynamic content, is as follows:  Your Benefit Periods   Your hospital and skilled nursing facility (SNF) stays are measured in benefit days  and benefit periods .  Every day that you spend in a hospital or SN F counts toward the benefit days in that benefit period.  A benefit period begins the day you first receive inpatient hospital services or, in certain circumstances, SNF services, and ends when you havent received any inpatient care in a hospital or inpat ient skilled care in a SNF for 60 days in a row.   Inpatient Hospital:  You have {#} out of 90 covered benefit days  remaining for the benefit period that began {Month DD, YYYY}.   Inpatient Lifetime Reserve: You have {#} out of 60 lifetime reserve days remain ing.  Inpatient Mental Health: You have {#} out of 190 mental health care days remaining.   Skilled Nursing Facility: You have {#} out of 100 covered benefit days  remaining for the benefit period that began {Month DD, YYYY}.  See your Medicare & You handbook for more information on benefit periods.  F. Medicare Preventive Services   This subsection is only for Part B assigned and unassigned MSNs.  It should be suppressed on all other types including Part A Inpatient, Hospice, Home Health, B of A, and DME.  For Part A Inpatient claims, this subsection should be replaced by the Your Benefit Periods subsection, described above.   POSITION   This subsection contains information of a fixed size. It does not vary in overall width or length.   It begins (3.9, 0.94).  This should top align with the How to Check This Notice subsection on the left column.  It is one -column or 259 points in width and 139 points in height.     FORMATTING   [GR 2.1] black rule  [GL 14] glyph [TH 3] subsection header, center vertically  to glyph  [GR 4.2] space after glyph  [TB 1.1] body text of intro paragraph  [GR 6] space between paragraph  [TB 1.1] body text of bulleted paragraph   DYNAMIC RULES   This section should be printed only on Part B assigned and unassigned notices.  The content  of the section is completely static.  CONTENT   Medicare Preventive Services  Medicare covers many free or low -cost exams and screenings to help you stay healthy.  For more information about preventive services:   Talk to your doctor.   Look at your Medicare & You handbook for a complete list.   Create an account on Medicare.gov.   G. Your Messages from Medicare   POSITION   The position of this subsection varies depending on the extended family member:  On Part A Inpatient and combined MSNs, it follows the Your Benefit Periods subsection, positioned 19 points from the baseline.  On Part B assigned and unassigned MSNs, it follows the Medicare Preventive Services subsection, with 19 points of space from the baseline.  On Hospice, Home Health (A) and (B), B of A, and DME MSNs, it has a fixed start location at (3.9, 0.94), and is top aligned with the How to Check This Notice subsection.  In all cases, it is one -column or 259 points in width with variable height from the dynamic content, depending on the length of the  CMS messages.    FORMATTING   [GR 2.1] black rule  [GL 9] glyph [TH 3] subsection header, center vertically to glyph  [GR 4.2] space after glyph  [TB 1.2] first sentence [TB 1.1] body text  [GR 6] space between paragraph  [TB 1.2] first sentence [TB 1.1] body text  [GR 6] space between paragraph  [TB 1.2] first sentence [TB 1.1] body text  [GR 6] space between paragraph  [TB 1.2] first sentence [TB 1.1] body text   DYNAMIC RULES   This subsection can accommodate up to four messages from CMS.  First and second messages must be no longer than 200 characters (inclusive of spaces) and third and fourth messages must be no longer than 250 characters (inclusive of spaces).   Current messages for this subsection, previously known as General Information Messages from Med icare, can be found on the CMS website: http://www.cms.gov/Medicare/Medicare -General -Information/MSN/index.html.  The first sentence, or the phrase up to the punctuation, will be bolded depending on the message.  Specific detail on where to bold will be provided by the CR of the variable messages.   10.3.6 - Specifications for Section 3: Claims (Rev.4007, Issued: 03- 22-18, Effective: 07- 01-18. Implementation: 07- 02-18)  A. Section Title  POSITION   This subsection contains information of a fixed size.  It is fi xed in width but may vary in overall length.   The content area begins (0, 0.22), 7 points from the baseline of the content described above under the Headers for Other Pages subsection. It is full -page or 540 points in width and variable in height.     FORMATTING   [GR 2.1] black rule  [TH 2] section header   DYNAMIC RULES   The language in this section varies for different members of the extended family of MSNs. See the specific content specifications below for details.   When there is a combined MSN for Part A, order the claims as follows:   Part A Inpatient   B of A   Home Health   Hospice   When there is a combined MSN for Part B or DME, order the claims as follows:   Assigned   Unassigned   PART A INPATIENT SPECIFICATIONS   CONTENT   Your Inpatient Claims for Part A (Hospital Insurance)   HOSPICE SPECIFICATIO NS  CONTENT   Your Hospice Claims for Part A (Hospital Insurance)   HOME HEALTH SPECIFIC ATIONS   CONTENT   Your Home Health Claims for Part A (Hospital Insurance)   PART B ASSIGNED AND DME ASSIGNED SPECIFI CATIONS   CONTENT   Your Claims for Part B (Medical Insurance)   PART B UNASSIGNED AN D DME UNASSIGNED SPE CIFICATIONS   CONTENT   Your Unassigned Claims for Part B (Medical Insurance)   B OF A  SPECIFICATIONS   CONTENT   Your Outpatient Claims for Part B (Medical Insurance)   B. Definitions of Columns   GLOBAL SPECIFICATION S  POSITION   The subsection usually begins (0, 0.94) or 28 points from the baseline of the Section Title subsection.  The content area is full -page or 540 points in width but is divided into two columns, each column 259 points in width with 22 point gutter in between.  The height is variable, depending on the length of the content, which is determined by the member of the extended family to which the MSN belongs.  The left column should always be longer than the right column.  If a definition is split between the columns, there should be at least two lines on both left and right columns.    FORMATTING   [TB 1.1] first paragraph and body text of subsequent paragraphs  [GR 6] space between paragraph  [TH 3] column- definition title  [GR 6] space between paragraph  [TB 1.2] definition terms, through colon [TB 1.1] definition  NOTE:  The column header is bolded with the rest of the type usually in regular Roman text.  There are a few instances where there may be additional bolded words within the body text.  DYNAMIC RULES   The language in this section differs for each member of the extended family of MSNs.  See the specific content specifications below for details.   PART A INPATIENT SPECIFICATIONS   CONTENT   Part A Inpatient Hospital Insurance helps pay for inpatient hospital car e, inpatient care in a skilled nursing facility following a hospital stay, home health care, and hospice care.  Definitions of Columns   Benefit Days Used: The number of covered benefit days you used during each hospital and/or skilled nursing facility stay.   (See page 2 for more information and a summary of your benefit periods.)   Claim Approved?: This column tells you if Medicare covered the inpatient stay.   Non-Covered Charges: This is the amount Medicare didnt pay.   Amount Medicare Paid: This is the amou nt Medicare paid your inpatient facility.   Maximum You May Be Billed: The amount you may be billed for Part A services can include a deductible, coinsurance based on your benefit days used, and other charges.   For more information about Medicare Part A cov erage, see your Medicare & You handbook.  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