(Medicare Claims Processing Manual)

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   PART B ASSIGNED SPEC IFICATIONS   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 1.5 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 al igned  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 c olumn Column 7:  38 points wide, [TH 5.1] left aligned with 5 point indent   DYNAMIC RULES   The content in this subsection is static.   CONTENT   Service Provided & Billing Code  Service Approved?  Amount Provider Charged Medicare- Approved Amount  Amount Medicare Paid  Maximum You May Be Billed  See Notes Below   PART B UNASSIGNED 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 and Exhibit 1.6 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 a ligned 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   Service Provided & Billing Code  Service Approved?  Amount Provider Charged Medicare- Approved Amount  Medicare Paid You  Maximum You May Be Billed  See Notes Below   B OF A  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 and Exhibit 1.2 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 al igned  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   n/a - the content in this subsection is static.   CONTENT   Service Provided & Billing Code  Service Approved?  Amount Facility Charged  Medicare- Approved Amount  Amount Medicare Paid  Maximum You May Be Billed  See Notes Below   DME ASSIGNED SPECIFI CATIONS   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 and Exhibit 1.7 for refere nce.  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 align ed 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   Quantity, Item/Service Provided & Billing Code  Item/Service Approved?  Amount Supplier Charged Medicare- Approved Amount  Amount Medicare Paid  Maximum You May Be Billed  See Notes Below   DME UNASSIGNED SPECI FICATIONS   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 and Exhibit 1.8 for reference.   Listed below are widths and formatt ing 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] rig ht 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   Quantity, Item/Service Provided & Billing Code  Item/Service Approved?  Amount Provider Charged Medicare- Approved Amount  Medicare Paid You  Maximum You May Be Billed  See Notes Below   E. Claim Content Line s  The content in the claim lines is beneficiary -specific and also differs for each member of the extended family of MSNs.  See the specific content specifications below for details.   POSITION   This subsection is directly after the claim column titles subsection.  It is full -page or 540 points in width and has a variable height, depending on the number of service line items in the given claims.  There are seven columns, corresponding to the column titles subsection.  All content is top aligned.   PART A INPATIENT SPECIFICAT IONS     FORMATTING   [GR 3.2] dotted rule [GR 2.2] black rule  Column 1:  [TB 2.1] benefit period, left aligned  Column 2:  [TB 2.1] approved status, right aligned Column 3:  [TB 2.1] amount charged, right aligned Column 4:  [TB 2.1] amount approved t, right aligned Column 5:  [TB 2.1] amount paid, right aligned, with 5 point indent  Column 6:  [TB 2.2] maximum, right aligned, with 3.5 point indent  Column 7:  [TB 2.2] note indicator, left aligned, with 5 point indent   NOTE:  When there is more than one service line, start with [GR 3.2] dotted rule to allow distinction between the services by the dotted rule.  The first line of column 6 will have [GR 2.2] on top and sides of the column.  Subsequent lines will have [GR 2.2] on the si des only.   DYNAMIC RULES   The content in this section is nearly entirely dynamically generated.  It includes the following content elements:   Description of Part A Inpatient Service   This column should contain the associated benefit -period start date.  La nguage options include:   Benefit period starting {Month DD, YYYY}   The date of service is listed with a spelled -out month, numeric day, and complete numeric year (e.g., October 15, 2021).   If there is no active benefit period because the claims are rejected, leave this field blank.  Benefit Days Used   This column shows the number of benefit days used during the hospital or skilled nursing facility admission , it indicates that a claim did not use benefit days because all the beneficiarys benefit days for th e given period have been exhausted, or there was no active benefit period because the claim was rejected .  Language options include:   1 day  {#} days  none remain  none   See Exhibit 2.7 for an example of the none remain option.  Claim Approved?   This column indicates if a claim item was approved or denied. It also indicates if a claim was adjusted.  Language options include:   Yes NO Yes -  adjusted  NO -  adjusted   See Exhibit 2.8 for an example of an adjusted claim (this example shows a Part B MSN, but it can be understood to also apply to other members of the extended family).   Non-Covered Charges   This column lists the amount of any claim charges that Medicare did not cover.  Non -covered services will include beneficiary -liable as well as provider -liable charges.  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.   Amount Medicare Paid  This column lists the amount that 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.   Maximum You May Be Billed   This column lists the beneficiarys total liability for the claim item.  This figure may be up to eight digits long, including cents: