(Medicare Claims Processing Manual)

FLASH IMAGE  Code  Name  Location  Size Sample  GL 1  HHS Seal  Page 1  72 pt x 72 pt   GL 2  Foreign -Language Footer  Page 1  540 pt x 27 pt  See section 10.3.3.J  GL 3  Check logo  Pay MSN  540 pt x 27 pt  See section 10.3.9.C  GL 4  Notice Title, Part A  Pay MSN  540 pt x 27 pt  See section 10.3.9.D  GL 5  Notice Title, Part B  Pay MSN  540 pt x 27 pt  See section 10.3.9.D  GL 6  Notice Title, Part A and Part B  Pay MSN  540 pt x 27 pt  See section 10.3.9.D  GL 7  HHS Seal for envelope  Envelope  57.5 pt x 57.5 pt  GL 8  Envelope Liner  Envelope   See section 10.3.10.D  GL 9  RRB Logo  Page 1 of RRB Part B MSNs  70 pt  x 70 pt    GR 7  Appeals Form  White fill and 0.5 pt black line all around box  N/A N/A GR 8  Space after Notice Title  No rule  17 points  0 points  GLYPHS  Smaller icons used in headers can be found in CMS Myriad font file as glyphs.  Code  Name  Location  Size Character Code  Sample  GL 9  Check This Notice  Page 2  15 pt x 15 pt    GL 10  Report Fraud  Page 2  15 pt x 15 pt    GL 11  Get Help  Page 2  15 pt x 15 pt    GL 12  Benefit Period  Page 2  15 pt x 15 pt    GL 13  Preventive Services  Page 2  15 pt x 15 pt    GL 14  Messages from Medicare  Page 2  15 pt x 15 pt    GL 15  Claims Continued Arrow  Claims  N/A    E. Language & Style Conventions   The MSN generally follows CMS conventions for style and language use.  One MSN -specific convention is noted below:   facility vs. provider vs. supplier   When describing the provider of the claimed services on an MSN, different terms are used for the different extended family members: Part A Inpatient and B of A  use facility, Part B (assigned and unassigned) use provider, and DME notices (assigned and unassigned) use supplier.   F. Organizing Principles for Specifications   The specifications that follow can be assumed to apply globally; when specifications vary by extended family member, the specifications will indicate which instructions apply globally and which relate to a particular member or members of the extended family.   The specificati ons are organized into chunks that relate to the individual subsections of the notice.  Each unit of specifications will typically contain:  POSITION    Instructions relating to the position of the subsection and its elements. The position coordinates are ba sed on top and left edge of margin set as (0, 0). Adjust measurement according to margins used.    Dimensions of content area and spacing between subsections.   Specifications per section, listed by page position: top, left column, then right column.  FORMA TTING    All figures are style and layout examples. Any magenta guides are for layout reference only and are not to be printed. Refer to exhibits for accurate printed examples.    Graphic example of subsection with type formats, graphic style and spacing used, and the content to which those formats are applied.   Line by line code containing type, graphic, and spacing styles.   DYNAMIC RULES    Description of any dynamically generated content within the section, and what rules should be applied to generate the content.   CONTENT    Language and other specific content that should appear.    General specifications are presented in Roman text. Type formats are indicated by bracketed codes (e.g., [TH 1.1]). Content that should be replicated on the MSN is presented in ita lic type; dynamic elements within the content are surrounded by curly brackets, {like this}.  In addition to figures for each subsection, exhibits are available for full MSNs for the base design family and worst -case scenarios.  Reference will be made to corresponding files as needed.   10.3.3 - Specifications for Section 1: Summary (Page 1)  (Rev. 11510, Issued: 07- 28-22, Effective: 01- 01-23, Implementation: 01- 03-23)  A. Notice Title   This section names the notice, specifies the function of the notice and the Medicare program under which the notices claims are paid, and identifies the Federal agencies responsible for generating the notice.   GLOBAL SPECIFICATIONS   POSITION   This subsection contains information of a fixed size.  It does not vary in overall width or length.   The content area begins (0, 0), and is full page or 540 points in width, 72 points in height.   The Department of Health & Human Services seal, a flash image, is 72 points by 72 points.  Indent 9 points from the seal to start the three t ext elements.   MACs are not to change the format of the Notice Title subsection in order to use double window envelopes.     FORMATTING  [GL 1] DHHS Seal  [TH 1.1] notice title  [TH 1.2] notice subtitle, indicating to which Medicare program the notice relate s [TB 3] notice descriptive tagline  NOTE:  Pagination specification on next subsection NOTE:  Use [TH 1.3] or [TH1.4] instead of [TH 1.2] for combined subtitle to fit in one line. NOTE:  Use [TH 1.4] only if using [TH 1.3] for combined subtitle will not fit i n one line.  DYNAMIC RULES   The notice subtitle is dynamically generated based on which type(s) of claims are present on the MSN:    Only claims paid by the Part A program;    Part B, B of A, or DME claims -  all of which are paid by the Part B program; or    A combination of Part A Inpatient and B of A claims that are paid by both Part A and Part B.    PART A INPATIENT, HOSPICE, AND HOME HEALTH (A) SPECIFICATIONS   CONTENT   Notices with only claims paid by the Part A program should have text content as follows:   Medicare Summary Notice  for Part A (Hospital Insurance)  The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid Services   PART B (ASSIGNED & UNASSIGNED), HOME HEALTH (B), B OF A, AND DME SPECIFICATIONS  CONTENT  Notices with  only claims paid by the Part B program should have text content as follows:   Medicare Summary Notice  for Part B (Medical Insurance)  The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid Services   COMBINED PART A INPATIENT AND B OF A SPECIFICATIONS   CONTENT   Notices that include both claims paid by the Part A program and also claims paid by the Part B programs -  as on notices that have both inpatient hospital claims and outpatient B of A claims -  should have text content  as follows:   Medicare Summary Notice  for Part A (Hospital Insurance) and Part B (Medical Insurance)  The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid Services   B. Pagination   The page number indicator, in the format Pag e 1 of #, must include the dynamically generated total page count for the notice in the second numeric position. Refer to specimen on section A for type style and placement relative to Notice title.   NOTE:  This specification is for pagination on page 1 onl y.  See section 10.3.4 for pagination included on page header for other pages.  POSITION   This subsection contains information of a fixed size. It does not vary in overall height but may vary in width depending on total page count.   The content area begins  (0, 6.75), right aligned from right margin. It is 90 points in width, 11 points in height.  FORMATTING  [TB 2.1] all text, right aligned   C. Recipient Address   POSITION   This subsection contains information of a variable size.   The content area begins (0, 1.35) with 32 point indent from left margin.  It is 1- column or 259 points in width with variable height, from 3 to 6 lines of text, not to exceed 82 points at 6 lines.  The name and address information is listed with 9- point clearance around the address when inserted into window envelope, to meet U.S. Postal Service regulations.  For specifications on window size and position, see section 10.3.10.  The position may vary for envelope to align with the recipient address of the i nserted MSN. Depending on the alignment, the address field of the printed MSN may be adjusted for ideal positioning.     [ The below figure is new.]     FORMATTING  [TB 1.1] all text, all caps   NOTE:  MACs may also use a smaller font size [TB 1.3] or [TB 1.4] if needed.  DYNAMIC RULES   All of the content in this subsection is dynamically generated.   At minimum, the beneficiary name and one - or two -line mailing address should be printed.  The name should be printed with the given name first, followed by any middle initial(s), the family name, then any suffixes (e.g., Jr.)   If applicable, when the beneficiarys primary residence is a healthcare facility, a facility name may be appended above the beneficiarys name.  As necessary, a second name (the beneficiary s legal representative) may be added above the beneficiarys name, followed by for.  The name should be printed in bold with the given name first, followed by any middle initial(s), the family name, then any suffixes (e.g., Jr.)   In the case that a legal representative is indicated, the designated recipients mailing address (if different from the beneficiarys address) should be used instead of the beneficiarys address.   The hierarchy of address should be as follows:   Legal representative  Beneficiarys temporary address   Beneficiarys permanent address   CONTENT   {BENEFICIARYS GIVEN NAME}{BENEFICIARYS MIDDLE INITIAL}{BENEFICIARYS FAMILY NAME}{BENEFICIARYS SUFFIX}  {PERMANENT STREET ADDRESS}  {SECOND LINE OF STREET ADDRESS}  {CITY}, {STATE ABREVIATION} {ZIP+4}   Or  {BENEFICIARYS GIVEN NAME}{BENEFICIARYS MIDDLE INITIAL}{BENEFICIARYS FAMILY NAME}{BENEFICIARYS SUFFIX}  {TEMPORARY ADDRESS FACILITY NAME OR STREET ADDRESS}  {SECOND LINE OF STREET ADDRESS}  {CITY}, {STATE ABREVIATION} {ZIP+4}   Or  {LEGAL REPRESENTATIVES GIVEN NAME}{LEGAL REPRESENTATIVES MIDDLE INITIALS}{LEGAL REPRESENTATIVES FAMILY NAME}{LEGAL REPRESENTATIVES SUFFIX} FOR  {BENEFICIARYS GIVEN NAME}{BENEFICIARYS MIDDLE INITIAL}{BENEFICIARYS FAMILY NAME}{BENEFICIARYS SUFFIX}  {LEGAL REPRESENTATIVES STREET ADDRESS}  {SECOND LINE OF STREET ADDRESS}  {CITY}, {STATE ABREVIATION} {ZIP+4}   NOTE : Comma between City and State is optional, to follow current practice.   D. Notice Details   This subsection provides a summary of whom the notice is for and what time period it covers.   POSITION   This subsection has a fixed size and position.  The subsection is printed on a gray highlight box.  The gray area begins (0, 2.75). It is one-column or 259 points in width and 108 points in height.   Indent in 8 points all around to begin content area.  The three lines of body content are organized into static and dynamic text.  Static text is in regular text, without changing content.  Indent 133 points in from left margin to start dynamic text (e.g.,  beneficiarys Medicare number) in bold.       FORMATTING   [GR 1] gray background  [TH 3] notice details header  [GR 4.1] spacing after header  [GR 3.1] dotted rule  [TB 2.1] static body content [TB 2.2] dynamic body content  [GR 3.1] dotted rule  [TB 2.1] stati c body content [TB 2.2] dynamic body content  [GR 3.1] dotted rule  [TB 2.1] static body content [TB 2.2] dynamic body content   DYNAMIC RULES