(Medicare Claims Processing Manual)

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.   If available, print the phone number associated with the billing department of the facility or provider that filed the claim for services.  If a specific billing contact number is not available, print the primary phone number for the facility or provider.  If no phone number for the facility or provider is available, suppress this content element and its preceding comma.   Facility Address   Print the facility or providers street address, city, state abbreviation, and ZIP code +4. Insert a comma between the street address and city, and between the city and state abbreviation.   If available, print the physical ad dress of the facility or provider.  If the physical address is not available, print the mailing or billing address for the facility or provider.  If no address for the facility or provider is available, suppress this content element.  Referring Provider   If the beneficiary was referred by a provider, print the providers full name here, preceded by the phrase Referred by. When printing a degree suffix (e.g., M.D.) with a name, place a period after the M and after the D. Referring physician name and an y suffix should be separated by a comma.   CONTENT   {Date(s) of Service}   {Facility/Provider Name}, {10 -digit phone number for facility/provider}  {Facility/Provider Street Address}{Facility/Provider State}{Facility/Provider ZIP+4}   Referred by {Provider Title}{Provider Given Name}{Provider Middle Initial}{Provider Family Name}   PART B (ASSIGNED AND  UNASSIGNED) SPECIFI CATIONS   FORMATTING   [GR 1] gray fill  [GR 2.1] black rule  [TH 4] Claim Service Date  [GR 5] space after text  [TB 2.2] provider name and telephone number  [TB 2.1] provider practice name and address  [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., O ctober 15, 2021 -  January 3 , 2022).  Provider Name   Print the complete name of the provider that filed the claim for services.  When printing a degree suffix (e.g., M.D.) with a name, place a period after the M and after the D.  The name and any suffix  should be separated by a comma.   Provider Phone Number   Print the providers 10- digit phone number, preceded by a comma to separate it from the provider name.  Enclose the area code within parentheses.  Insert a dash between the third and fourth digit of the local phone number.   If available, print the phone number associated with the billing department of the provider that filed the claim for services.  If a specific billing contact number is not available, print the primary phone number for the provider.  If no phone number for the provider is available, suppress this content element and its preceding comma.  Provider Practice Name and Address   If applicable, print the name of the practice or facility associated with the provider.  Print the providers st reet address, city, state abbreviation, and zip code +4. Insert a comma between the practice name, street address and city, and between the city and state abbreviation.   Whenever possible, the address that is printed should be the physical address of the provider.  If the physical address is not available, use the mailing or billing address for the provider.  If no address for the provider is available, suppress this content element.  Referring Provider   If the beneficiary was referred to the provider by an other provider, print the referring providers full name here, preceded by the phrase Referred by.  When printing a degree suffix (e.g., M.D.) with a name, place a period after the M and after the D.  Referring provider name and any suffix should be separated by a comma.   CONTENT   {Date(s) of Service}   {Provider Title}{Provider Given Name}{Provider Middle Initial}{Provider Family Name} {, Provider Suffix}, {10 -digit phone number for provider}   {Provider Practice Name}{Provider Street Address}{ Provide r State}{ Provider ZIP+4}   Referred by {Provider Title}{Provider Given Name}{Provider Middle Initial}{Provider Family Name}   DME (ASSIGNED AND UN ASSIGNED) SPECIFICAT IONS   FORMATTING  [GR 1] gray fill  [GR 2.1] black rule  [TH 4] Claim Service Date  [GR 5] space after text  [TB 2.2] supplier name and telephone number  [TB 2.1] supplier practice name and address and any referring/ordering 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).  Supplier Name   Print the complete name of the supplier that filed the c laim for services.  If the supplier is a physician, when printing a degree suffix (e.g., M.D.) with the name, place a period after the M and after the D.  The name and any suffix should be separated by a comma.   Supplier Phone Number   Print the supplie r 10-digit phone number, preceded by a comma to separate it from the supplier name.  Enclose the area code within parentheses.  Insert a dash between the third and fourth digit of the local phone number.   If available, print the phone number associated wit h the billing department of the supplier that filed the claim for services.  If a specific billing contact number is not available, print the primary phone number for the supplier.  If no phone number for the supplier is available, suppress this content el ement and its preceding comma.   Supplier Address   Print the suppliers street address, city, state abbreviation, and ZIP code +4. Insert a comma between the practice name, street address and city, and between the city and state abbreviation.   If available,  print the physical address of the supplier.  If the physical address is not available, print the mailing or billing address for the supplier.  If no address for the supplier is available, suppress this content element.   Ordering Provider   If the beneficia rys supplies were ordered by a provider, print the ordering providers full name here, preceded by the phrase Ordered by.  When printing a degree suffix (e.g., M.D.) with a name, place a period after the M and after the D.  Ordering physician name and any suffix should be separated by a comma.  If the NPI submitted on the claim is not on file, use the name as shown on the claim.  Suppress the Ordered by line if not able to identify the doctor.  For A/B MACs (B), if the ordering physician is the sam e as any performing physician on the claim, suppress the ordering physician line.  If the NPI submitted on the claim is not on the A/B MAC (B)s file, suppress the Ordered by line.   CONTENT   {Date(s) of Service}   {Supplier Name}, {10 -digit phone number f or supplier}   {Supplier Street Address}{Supplier State}{Supplier ZIP+4}   Ordered by {Provider Title} {Provider Given Name}{Provider Middle Initial}{Provider Family Name}   D. Claim Column Titles   The language used for the column headers differs for each mem ber of the extended family of MSNs.  See the specific content specifications below for details.     PART A INPATIENT SPECIFICATIONS   POSITION/FORMATTING   This subsection is directly after the claims  header subsection.  It is full -page or 540 points in width and 42.25 points in height.  Content should have 5 points of space from top and 7 points of space from the bottom.  There are seven columns with varying widths.  All content is to be bottom aligne d.  See figure 10.3.6.D1 and Exhibit 1.1 for reference.   Listed below are widths and formatting for each column:   Column 1:  188 points wide, no content  Column 2:  42 points wide, [TH 5.1] right aligned  Column 3:  62 points wide, [TH 5.1] right aligned  Column  4: 66 points wide, [TH 5.1] right aligned  Column 5:  71 points wide, [TH 5.1] right aligned with 5 point indent  Column 6:  73 points wide, [TH 5.2] right aligned with 3.5 point intent, white text on black fill and [GR 2.2] on both sides of the column Column  7: 38 points wide, [TH 5.1] left aligned with 5 point indent   DYNAMIC RULES   n/a - the content in this subsection is static.   CONTENT   (blank)  Benefit Days Used  Claim Approved?  Non-Covered Charges  Amount Medicare Paid  Maximum You May Be Billed  See Notes B elow   HOSPICE AND HOME HEA LTH SPECIFICATIONS   POSITION/FORMATTING  This subsection is directly after the claims  header subsection.  It is full -page or 540 points in width and 42.25 points in height.  Content should have 5 points of space from the top and 7 points of space from the bottom.  There are seven columns with varying widths.  All content is to be bottom aligned.  See figure 10.3.6.D2, Exhibit 1.3, and Exhibit 1.4 for reference.   Listed below are widths and formatting for each column:   Column 1:  174 points wide, [TH 5.1] left aligned  Column 2:  52 points wide, [TH 5.1] right aligned  Column 3:  66 points wide, [TH 5.1] right aligned  Column 4:  66 points wide, [TH 5.1] right aligned  Column 5:  71 points wide, [TH 5.1] right aligned with 5 point indent  Column 6:  73 points wide, [TH 5.2] right aligned with 3.5 point intent, white text on black fill and [GR 2.2] on both sides of the column Column 7:  38 points wide, [TH 5.1] left aligned with 5 point indent   DYNAMIC RULES   The content in this subsection is static.   CONTENT   Quantity & Service Provided Service Approved?  Amount Provider Charged Medicare- Approved Amount  Amount Medicare Paid  Maximum You May Be Billed  See Notes Below