(Medicare Claims Processing Manual)

Upon the beneficiarys request, create and send MSNs for previously suppressed claims.   Do not suppress claims from MSNs when any of the follow ing conditions apply:    One or more services were denied because one of the exclusions from Medicare coverage in 1862(a)(1)  of the Social Security Act (the Act) applies;    The claim is denied as not filed within the time limits required by 1842(b)(3)  of the Act;    The claim is denied in full or in part because the beneficiary was not enrolled in Part A or B of Medicare when the services in question were provided; or    An initial determination is made on a claim not later than the 45 -day period beginning on the date the A/B MAC (A), (B), (HHH), or DME MAC receives a claim.  10.3.8 - Specifications for Se ction 4 (Last Page): Denials and Appeals  (Rev. 10180, Issued: 06- 12-2020, Effective: 10- 01-2020, Implementation: 10-05-2020)    This section of the MSN helps beneficiaries understand how to handle denied claims; it also explains how and when to file an appeal. This section should be printed in its entirety on exactly one page, and it should always appear on the MSNs final page. It  can appear on either the front or reverse of a sheet.    A. Section Title    POSITION    This subsection contains information of a fixed size. It does not vary in overall width or length.    The content area begins (0, 5), 7 points from the baseline of Headers of Other Pages subsection. It is full -page or 540 points in width and 24 points in height.        FORMATTING    [GR 2.1] black rule  [TH 2] section header    DYNAMIC RULES  N/A -  this section is static    CONTENT  How to Handle Denied Claims or File an Appeal    B. Get More Details    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, 0.94) or 28 points from the baseline of the Section Title subsection. It is one -column or 259 points in width and 167 points in height.        FORMATTING    [GR 2.1] black rule  [TH 3] subsection header  [GR 4.1] space after header  [TB 1.2] highlight first sentence [TB 1.1] body text  [GR 6] space between paragraph  [TB 1.1] body text    DYNAMIC RULES    N/A -  this section is static    PART A INPATIENT AND B OF A SPECIFICATIONS    CONTENT    Get More Details    If a claim was denied, call or write the hospital or facility and ask for an itemized statement for any claim.  Make sure they sent in the right information.  If they didnt, ask the facility to contact our claims office to correct the error.  You can ask the facility for an itemized statement for any service or claim.    Call 1 -800-MEDICARE (1 -800-633-4227) for more information about a coverage or payment decision on this notice, including laws or policies used to make the decision.    PART B (ASSIGNED AND UNASSIGNED), HOSPICE, AND HOME HEALTH  SPECIFICATIONS    CONTENT    Get More Details    If a claim was denied, call or write the provider and ask for an itemized statement for any claim. Make sure they sent in the right information.  If they didnt, ask the provider to contact our claims office to correct the error.  You can ask the provider for an itemized statement for any service or claim.    Call 1 -800-MEDICARE (1 -800-633-4227) for mor e information about a coverage or payment decision on this notice, including laws or policies used to make the decision.    DME (ASSIGNED AND UNASSIGNED) SPECIFICATIONS    CONTENT    Get More Details    If a claim was denied, call or write the supplier and  ask for an itemized statement for any claim. Make sure they sent in the right information.  If they did not, ask the supplier to contact our claims office to correct the error.  You can ask the supplier for an itemized statement for any item or claim.    Call 1 -800-MEDICARE (1 -800-633-4227) for more information about a coverage or payment decision on this notice, including laws or policies used to make the decision.    C. If You Disagree    POSITION    The position of this subsection is dynamic.  The content area begins 19 points from the baseline of the Get More Details subsection.  It is one -column or 259 points in width and 132 points in height.  The last line has a black rule around the appeal due da te.  The date field is 158 points wide.         Formatting    [GR 2.1] black rule  [TH 3] subsection header  [GR 4.1] space after header  [TB 1.2] highlight first sentence [TB 1.1] body text  [GR 6] space between paragraph  [TB 1.1] body text  [TB 1.2] appeals due date, center aligned [GR 2.2] highlight edges of Column 2    DYNAMIC RULES    This subsection contains a dynamically generated date: the beneficiarys appeal deadline.  The date printed should be 125 days from the notice date in the No tice Details subsection of Part 1.  The date is listed with a spelled -out month, numeric day, and complete numeric year (e.g., October 15, 2021).    CONTENT    If You Disagree with a Coverage Decision, Payment Decision, or Payment Amount on this Notice, Yo u Can Appeal    Appeals must be filed in writing.  Use the form to the right.  Our claims office must receive your appeal within 120 days from the date you get this notice.    We must receive your appeal by:   {Month DD, YYYY}    D. If You Need Help Filing Your Appeal    GLOBAL SPECIFICATIONS    POSITION    The position of this subsection is dynamic.  The content area begins 19 points from the baseline of the If You Disagree subsection.  It is one -column or 259 points in width and 190 points in height.        FORMATTING    [GR 2.1] black rule  [TH 3] subsect ion header  [GR 4.1] space after header  [TB 1.2] highlight first sentence [TB 1.1] body text  [GR 6] space between paragraph  [TB 1.2] highlight first sentence, [TB 1.1] body text  [GR 6] space between paragraph  [TB 1.2] highlight first sentence [TB 1.1]  body text    DYNAMIC RULES    If the mailing address is that of the legal representative, the beneficiarys address state should be used to identify the SHIP contact number, not that of the legal representative.    NOTE : If the mailing address is that of the legal representative and the beneficiarys address indicates that the beneficiary lives outside of the 50 U.S. states and U.S. territories, then the final paragraph on page 2 should be suppressed. See alternate langu age in the Content specifications below.    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     If You Need Help Filing Your Appeal  Contact us: Call 1 -800-MEDICARE or your State Health Insurance Program (see page 2) for help before you file your written appeal, including help appointing a representative.    Call your facility: Ask your facility for any information that may help you.    Ask a friend to help: You can appoint someone, such as a family member or friend, to be your representative in the appeals process.    Or, if the MSN mailing address is outside the 50 states, use the following language:  If You Need Help Filing Your Appeal    Contact us: Call 1 -800-MEDICARE for help before you file your written appeal, including help appointing a representative.     Call your facility: Ask your facility for any information that may  help you.    Ask a friend to help: You can appoint someone, such as a family member or friend, to be your representative in the appeals process.    PART B (ASSIGNED AND UNASSIGNED), HOSPICE, AND HOME HEALTH  SPECIFICATIONS    CONTENT    If You Need Help Filing Your Appeal    Contact us: Call 1 -800-MEDICARE or your State Health Insurance Program (see page 2) for help before you file your written appeal, including help appointing a representative.    Call your provider: Ask your provider fo r any information that may help you.    Ask a friend to help: You can appoint someone, such as a family member or friend, to be your representative in the appeals process.    Or, if the MSN mailing address is outside the 50 states, use the following language:    If You Need Help Filing Your Appeal    Contact us: Call 1 -800-MEDICARE for help before you file your written appeal, including help appointing a representative.    Call your facility: Ask your facility for any information that may help you.    Ask a friend to help: You can appoint someone, such as a family member or friend, to be your representative in the appeals process.    DME (ASSIGNED AND UNASSIGNED) SPECIFICATI ONS    CONTENT    If You Need Help Filing Your Appeal    Contact us: Call 1 -800-MEDICARE or your State Health Insurance Program (see page 2) for help before you file your written appeal, including help appointing a representative.    Call your supplier: Ask your supplier for any information that may help you.    Ask a friend to help: You can appoint someone, such as a family member or friend, to be your representative in the appeals process.    Or, if the MSN mailing address is outside the 50 states, use the following language:    If You Need Help Filing Your Appeal    Contact us: Call 1 -800-MEDICARE for help before you file your written appeal, including help appointing a representative.     Call your facility: Ask your facility for any information that m ay help you.    Ask a friend to help: You can appoint someone, such as a family member or friend, to be your representative in the appeals process.    E. Find Out More    POSITION    The position of this subsection is dynamic.  The content area begins 19 points from the baseline of the If You Need Help Filing Your Appeal subsection.  It is one -column or 259 points in width and 72 points in height.       FORMATTING    [GR 2.1] black rule  [TH 3] subsection header  [GR 4.1] space after header  [TB 1.1] body text    CONTENT    Find Out More About Appeals    For more information about appeals, read your Medicare & You handbook, or visit us online at www.medicare.gov/appe als.    F. File an Appeal in Writing    GLOBAL SPECIFICATIONS    POSITION    This subsection contains information of a fixed size.  It does not vary in overall width or length.    This subsection begins (3.9, 0.94).  This should top align with the Get More Details subsection in the left column.  It is one -column or 259 points in width and 652 points in height.    Indent in 8 points top and left and 16 points from right to begin content area.  Tab 12 points from left to start appeal instructions and fill -in box.    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