(Medicare Claims Processing Manual)

The beneficiary fill -in box in Step 3 is 218 points in width and 22 points in height.    The telephone number fields are split further, with 19 points of width for each n umber and 7 points of space in between the fields.  Any space after the 10 digit fields should be left as gray fill.      Revised figure 10.3.8.F    FORMATTING    [GR 1] gray fill  [TH 3] subsection header  [GR 4.1] space after header  [TB 2.1] body text  [GR 4.1] space after header  [TB 2.2] step 1 [TB 2.1] body text  [GR 4.1] space after header  [TB 2.2] step 2 [TB 2.1] body text  [GR 4.1] space after header  [TB 2.2] step 3 [TB 2.1] body text  [GR 4.1] space after header  [TB 2.1] fill in category  [GR 5 ] space after text  [GL 7] fill in box    [GR 6] space after text  [TB 2.1] fill in category  [GR 5] space after text  [GL 7] fill in boxes  [GR 4.1] space after header  [TB 2.2] steps 4 -  7 [TB 2.1] body text  [GR 4.1] space after header  [TB 2.2] MAC address    DYNAMIC RULES    In Step 7 of the File an Appeal in Writing subsection, beneficiaries are instructed where to mail their appeals material.  The mailing address listed should be the preferred mailing address of the MAC generating the  MSN.    The address should appear in the following format:    First Line:  Medicare Claims Office (static text)  Second Line:   c/o { A/B MAC (A), (B), (HHH), or DME MAC Name} Third Line:    { MAC Street Address or PO Box, Suite Number}   Fourth Line:   { MAC City}, {ST} {ZIP+4}    If the MAC uses another name to refer to the Medicare Claims Office, add an additional line after the second line with an attn: to refer to the department.  The first line should stay static for all return addresses.     First Line:  Medicare Claims Office (static text)   Second Line:   c/o {A/B MAC (A), (B), (HHH), or DME MAC Name}   Third Line:  attn: {Appeals Department Name}   Fourth Line:   {MAC Street Address or PO Box, Suite Number}   Fifth Line:   {MAC City}, {ST} {ZI P+4}    When there is a combined MSN that has Part A Inpatient claims with Hospice and/or Home Health claims, use the content for Part A Inpatient specification.     PART A INPATIENT AND B OF A SPECIFICATIONS    CONTENT    File an Appeal in Writing    1 Circle the service(s) or claim(s) you disagree with on this notice.    2 Explain in writing why you disagree with the decision.  Include your explanation on this notice or, if you need more space, attach a separate page to this notice.    3 Fill in all of the following:    Your or your representatives full name (print)    Your telephone number    Your complete Medicare number   4 Include any other information you have about your appeal.  You can ask your facility for any information that will help you.    5 Write your Medicare number on all documents that you send.    6 Make copies of this notice and all supporting documents for your records.    7 Mail this notice and all supporting documents to the following address:    Medicare Claims Office   c/o {A/B MAC (A), (B), (HHH), or DME MAC Name}   {MAC Street Address}  {MAC City}, {ST} {ZIP+4}    PART B (ASSIGNED AND UNASSIGNED), HOSPICE, AND HOME HEALTH  SPECIFICATIONS    CONTENT    File an Appeal in Writing    1 Circle the service(s) or claim(s) you d isagree with on this notice.    2 Explain in writing why you disagree with the decision.  Include your explanation on this notice or, if you need more space, attach a separate page to this notice.    3 Fill in all of the following:    Your or your representatives full name (print)    Your telephone number    Your complete Medicare number    4 Include any other information you have about your appeal.  You can ask your provider for any information that will help you.    5 Write your Medicare number on all documents that you send.    6 Make copies of this notice and all supporting documents for your records.    7 Mail this notice and all supporting documents to the following address:    Medicare Claims Office   c/o {A/B MAC (A), (B), (HHH), or DME MAC Name}   {MAC Street Address}  {MAC City}, {ST} {ZIP+4}    DME (ASSIGNED AND UNASSIGNED) SPECIFICATIONS    CONTENT    File an Appeal in Writing    1 Circle the item(s) or claim(s) you disagree with on this notice.    2 Explain in writing why you disagree with the decision.  Include your explanation  on this notice or, if you need more space, attach a separate page to this notice.      3 Fill in all of the following:    Your or your representatives full name (print)    Your telephone number    Your complete Medicare number    4 Include any other information you have about your appeal. You can ask your supplier for any information that will help you.    5 Write your Medicare number on all documents that you send.    6 Make copies of this notice and all supporting documents for your records.    7 Mail this notice and all supporting documents to the following address:    Medicare Claims Office   c/o {A/B MAC (A), (B), (HHH), or DME MAC Name}  {MAC Street Address}  {MAC City }, {ST} {ZIP+4}    10.3.9 - Specifications for Pay MSN Cover Sheet & Check  (Rev. 3210, Issued: 03- 03-15, Effective: 04- 16-15. Implementation: 04- 16-15)  From time to time, beneficiaries may receive an MSN that includes a check, refunding an overpayment made (most often) for Part B services, either assigned or unassigned.  The instructions below describe the cover sheet and check page.  This page is inserted before the notice itself.   The MACs are not required to change their process of producing checks, but encouraged to revise fonts and formatting to reflect the redesign.  The check must have the DHHS seal, not the CMS logo as previously used.   A. Recipient Address   POSITION   This subsection contains information of a variable size.  The following specifi cation is the same as Section 10.3.3.C, Recipient Address subsection.   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 point s at 6 lines.  See figure 10.3.3.C for layout reference.   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 a nd position, see section 10.3.8.A.  FORMATTING   [TB 1.1] all text, all caps   DYNAMIC RULES   All of the content in this subsection is dynamically generated. It should be identical to the recipient address printed on page 1 of the MSN.  Please see Section 10.3.3, part C, for detailed dynamic rules for the recipient address.   CONTENT   The recipient address printed here should be identical to the recipient address printed on page 1 of the MSN. Please see Section 10.3.3, part C, for detailed information on the content of the recipient address.   B. Check Notification   This subsection contains a high- priority message to beneficiaries indicating that a check is enclosed.   POSITION  This subsection contains static text content.   The content area begins (0, 4), is one -column or 259 points in width with 64 points in height.     FORMATTING   [TH 4] Big Header, all caps, center aligned   DYNAMIC RULES   N/A -  this section is static.   CONTENT   MEDICARE PART B CHECK  DO NOT DESTROY  PLEASE CASH AS SOON AS POSSIBLE    C. Chec k  This subsection contains the check refunding funds to the beneficiary.  The positioning, formatting, and content of this dynamic content is variable, depending on the check-printing practices of each MAC.  The one consistent element is the DHHS seal, described below.  POSITION   Align to the top of the top of the check content area. Content should be centered horizontally.   The content area is 193 points in width with 53 points in height.  See Exhibit 2.13 for layout reference.      FORMATTING   [GL 3] Check logo   DYNAMIC RULES   As noted above, the dynamic content on the check is variable, depending on the check -printing practices of each MAC.   CONTENT   As noted above, the dynamic content on the check is variable, depending on the check -printing practice s of each MAC.   D. Notice Title on Check Page   Depending on the check -printing practices of the MAC, the Notice Title subsection on the MSN may be repeated on the check page. Glyph files, GL 4 (Part A), GL5 (Part B) and GL6 (Part A and B combined), are ava ilable as flash images of the 3 different types of Titles.  See Section 10.3.3.A for detailed specifications.  10.3.10 - Specifications for Envelopes  (Rev. 3210, Issued: 03- 03-15, Effective: 04- 16-15. Implementation: 04- 16-15)  The envelopes in which MSNs are mailed will be consistent in format, rather than varying depending on which MAC is responsible for printing and mailing the MSN.  The envelopes will feature the DHHS seal, not the individual MAC logo or the CMS logo.  Content will be printed using Mini on for the address and Myriad in all caps for any additional information.  Both the DHHS seal and the content will be printed in CMS blue, or Pantone 300 U.   The MSN may be mailed in one of three sizes of envelopes: standard #10 (4.125 x 9.5), half size (6 x 9), or full size (9 x 12).  All MACs are encouraged to print on customized envelopes with adjusted window position to show the recipient address of the MSN when inserted in the envelope.  Therefore, coversheets or address labels will no longer be needed for any of the envelope sizes.  (The only exception is in the case of Pay MSNs, where the check will be part of a cover sheet containing the beneficiarys mailing address; see the section above for check cover -sheet instructions, and see below for s pecifications for the front of Pay MSN envelopes.)   See Exhibit 2.14 for examples of the three different sizes of non- pay envelopes and the Pay MSN envelope.   A. Front of Non -Pay MSN Envelopes   POSITION OF CONTENT   The front of the envelope contains inform ation of a fixed size. It does not vary in overall width or length.   The Department of Health & Human Services seal, an imported image, is located (0.375, 0.25).  It measures 57 points in width and 57.5 points in height.  The text element starts (1.25, 0.3), indented 6 points from the seal.  It measures 210 points in width and 75 points in height.    POSITION OF ADDRESS WINDOW   For all sizes of the envelope, the window measures 4.5 inches in width and 1.5 inches in height with rounded corners.   On standard #10 and half -size envelopes, the window is located at (0.75, 2.06) from left top corner.  To meet USPS requirements, the window on the standard #10 envelope should be placed 0.625 from the bottom.   [The below figure has been revised.]     On full-size envelopes, the window is located at (0.5, 2) from left top corner.      [The below figure is new.]     See Exhibit 2.14 for layout reference.   FORMATTING