(Medicare Claims Processing Manual)

Total for Claim #{Claim Number}   Insert dashes in the claim number as indicated by the system.   Total Amount Suppli er Charged   This column lists the sum of the line -item amounts above of the charges the supplier submitted. This figure may be up to eight digits long, including cents:   ${###,###.##}  Insert a comma between the thousands digit and the hundreds digit of any four -figure or higher amount. Use $0.00 for zero.   Total Medicare- Approved Amount   This column lists the sum of the line -items amounts above for what Medicare allows for the item or service.  This figure may be up to eight digits long, including cents :  ${###,###.##}  Insert a comma between the thousands digit and the hundreds digit of any four -figure or higher amount.  Use $0.00 for zero.   Total Amount Medicare Paid   This column lists the sum of the line -item amounts above for what Medicare paid toward the claim.  This figure may be up to eight digits long, including cents:  ${###,###.##}  Insert a comma between the thousands digit and the hundreds digit of any four -figure or higher amount.  Use $0.00 for zero.   Total Maximum You May Be Billed   This column lists the sum of the line -item amounts above showing the beneficiarys liability for the claim item.  This figure may be up to eight digits long, including cents:   ${###,###.##}  Insert a comma between the thousands digit and the hundreds dig it of any four -figure or higher amount.  Use $0.00 for zero.   See Notes Below   This column displays indicators that refer to explanations listed in the Notes for Claims Above subsection, which is printed at the bottom of the page when applicable.  See the description in the Claim Content Lines specifications for detailed instructions. Note that the Claim Total Line differs from the Claim Content Lines in regards to claim notes: A maximum of three notes are allowed per total line, rather than the five notes allowed for a content line.  No more than three note indicators should ever be listed here.   CONTENT   Total for Claim #{Claim Number}  ${###,###.##} ${###,###.##} ${###,###.##} ${###,###.##}  {NOTE INDICATOR(S)}   DME UNASSIGNED SPECI FICATIONS   See figure 10.3.6.F2 or Exhibit 1.8 for layout reference.   FORMATTING   [GR 3.2] dotted rule [GR 2.2] black rule  Columns 1 -2: [TB 2.2] claim number, left aligned  Column 3:  [TB 2.1] amount charged total, right aligned  Column 4:  [TB 2.1] approved total, right aligned  Column 5:  [TB 2.1] amount paid total, right aligned, with 5 point indent  Column 6:  [TB 2.2] maximum total, right aligned, with 3.5 point indent  Column 7:  [TB 2.2] note indicator, left aligned, with 5 point indent   NOTE:  The first line of column 6 will have [ GR 2.2] on top, bottom, and both sides of the column as a highlight.   DYNAMIC RULES   The content in this section is nearly entirely dynamically generated.  It includes the following content elements:   Claim Number   This column lists the claim number for the claim, preceded by a static text phrase:   Total for Claim #{Claim Number}   Insert dashes in the claim number as indicated by the system.   Total Amount Supplier Charged  This column lists the sum of the line -item amounts above of the charges the supplier  submitted. This figure may be up to eight digits long, including cents:   ${###,###.##}  Insert a comma between the thousands digit and the hundreds digit of any four -figure or higher amount.  Use $0.00 for zero.   Total Medicare- Approved Amount   This col umn lists the sum of the line -items amounts above for what Medicare allows for the item or service.  This figure may be up to eight digits long, including cents:   ${###,###.##}  Insert a comma between the thousands digit and the hundreds digit of any four -figure or higher amount.  Use $0.00 for zero.   Total Amount Medicare Paid You   This column lists the sum of the line -item amounts above for what Medicare paid the beneficiary toward the claim.  This figure may be up to eight digits long, including cents:   ${###,###.##}  Insert a comma between the thousands digit and the hundreds digit of any four -figure or higher amount.  Use $0.00 for zero.   Total Maximum You May Be Billed   This column lists the sum of the line -item amounts above showing the beneficiarys liability for the claim item.  This figure may be up to eight digits long, including cents:   ${###,###.##}  Insert a comma between the thousands digit and the hundreds digit of any four -figure or higher amount.  Use $0.00 for zero.   See Not es Below   This column displays indicators that refer to explanations listed in the Notes for Claims Above subsection, which is printed at the bottom of the page when applicable.  See the description in the Claim Content Lines specifications for detailed in structions.  Note that the Claim Total Line differs from the Claim Content Lines in regards to claim notes: A maximum of three notes are allowed per total line, rather than the five notes allowed for a content line.  No more than three note indicators should ever be listed here.   CONTENT   Total for Claim #{Claim Number}  ${###,###.##} ${###,###.##} ${###,###.##} ${###,###.##}  {NOTE INDICATOR(S)}   G. Notes for Claims Above   This subsection is dynamically generated when any of the claim line items on the page has an explanatory note.  Note that the notes are limited to only those claim items on each page.  See Exhibit 2.9, Exhibit 2.10, Exhibit 2.11, and Exhibit 2.12 for multiple examples of the relationship between claims data and claim notes.   POSITION   This subsection is built dynamically from bottom up in relation to the claim section above.  It is full -page or 540 points in width with a variable height depending on the content length.  Indent in 16 points from the right margin to start notes text.   There sh ould be a minimum of 12 points space between the top of this subsection and Claim Total Line subsection.  If there is a continuation box, see next subsection, 10.3.6.I, for spacing specifications.     FORMATTING   [GR 2] black rule  [TB 2.2] subsection header  [GR 4.2] space after  [TB 2.2] alphabetic note indicator(s) [TB 1.1] note body text   NOTE:  If there are multiple notes, insert [GR 4.2] space before the note indicator and body text.  DYNAMIC RULES   This subsection is dynamically generated when any o f the claim line items on the page is linked to an explanatory note.  If there are no messages to be printed, suppress the entire Notes for Claims Above subsection.  Do not print the Notes for Claims Above subsection without at least one complete message f ollowing it on the same page.   The section includes three elements:   Static Subsection Header   See the content section below for this language.   Note Indicator(s)   See the description in the Claim Content Lines specifications for detailed instructions on the generation of the alphabetic note indicators.  Those instructions should be followed here, with the exception that each individual note indicator should be placed on a separate line.  List the note indicators in alphabetic order.   Identical notes should not  be repeated.  For example, even if the note indicator F appears on multiple occasions in the claim lines on the page, the F indicator and the explanatory note linked to F should only appear once in this section.  Explanatory Note   Each note indicator should be followed by an explanatory note relating to the claim data on the page.  These explanatory notes are linked to the claim items in the system, and a complete list of the note text is available on the CMS website at: http://www. cms.gov/Medicare/Medicare- General -Information/MSN/index.html.   CONTENT   Notes for Claims Above  {Note Indicator(s)} {Explanatory Note(s)}   H. Continued Claims -  Continuation Box   This section is dynamically generated when the claims continue on the next page or a claim is split across the page.  See Exhibit 2.9, Exhibit 2.10, Exhibit 2.11, and Exhibit 2.12 for multiple examples of continuing claims.  POSITION   This element is fixed in size, 84 points in width and 18 points in height.  The white type and glyph arrow are centered horizontally and vertically within the black filled box.  The horizontal position is fixed, but the vertical position is dynamic.  The element is right aligned on top right of the Notes for Claims Above subsection.    FORMATTING   [TB 2 .2] Continued [GL 9] arrow, right aligned, white on black fill   DYNAMIC RULES   If the claim above splits across pages, also include the continued footer at the bottom of the claim in addition to this element.   CONTENT   Continued [arrow glyph]   I. Breaking Claims -  Continuation Footer   This section is dynamically generated when a claim is split across the page.  When there is a split, include this subsection instead of the Claim Total Line subsection.  The specifications of the columns are the same, dependen t on MSN type, with dynamic claim number and static text.  See Exhibit 2.9, Exhibit 2.10, Exhibit 2.11, and Exhibit 2.12 for multiple examples of continuing claims.   POSITION   This subsection is directly after the claim content lines subsection with fixed content area.  It is full- page or 540 points in width and 21 points in height.  There are six columns.  The five right -most columns correspond to the column sizes in the Claims Content Lines subsection; the first column, containing the claim number, is equivalent in width to the first and second columns in the Claims Content Lines subsection. All content is to be top aligned.     FORMATTING   [GR 3.2] dotted rule [GR 2.2] black rule  Columns 1 -2: [TB 2.2] claim number, left aligned  Column 3:  (blank)  Column 4:  (blank)  Column 5:  (blank)  Column 6:  [TB 2.2] continued tag, right aligned, with 3.5 point indent  Column 7:  (blank)   NOTE:  There are no black rules to highlight Column 6 as the Claim Total Line subsection.  DYNAMIC RULES   Repeat at the bottom of the claim as needed if the Claim Total Line subsection is not on the page.   CONTENT   Claim #{Claim Number}  (continued)   J. Breaking Claims -  Continuation Header   This section is dynamically generated when a claim is split across two or more pages.  When there is a split, include this subsection on subsequent pages at the top of the page before continuing the claims followed by the Claim Column Titles subsection and Claim Content Lines subsection.  See Exhibit 2.9, Exhibit 2.10, Exhibit 2.11, and Exhibit 2.12 for mul tiple examples of continuing claims.   POSITION   This subsection is directly after the page header.  It is fixed in size, full- page or 540 points in width and 25 points in height.     FORMATTING   [GR 2.1] black rule  [TB 2.2] date / provider continued [GR 3.4] dotted rule w/ space before  DYNAMIC RULES  Repeat header on subsequent pages as needed if the Claim Total Line subsection is not on the page.   PART A INPATIENT AND B OF A  SPECIFICATIONS   CONTENT   {Date of Service} / {Facility name} continued   HOSPICE, HOME HEALTH AND PART B (ASSIGNED AND UNASSIGNED) SPECIFICATIONS   CONTENT   {Date of Service} / {Provider name} continued   DME (ASSIGNED AND UN ASSIGNED) SPECIFICAT IONS   CONTENT   {Date of Service} / {Supplier name} continued    10.3.7 - Claims Calcu lations (Rev. 3210, Issued: 03- 03-15, Effective: 04- 16-15. Implementation: 04- 16-15)