(Medicare Claims Processing Manual)

Item/Service 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 ex tended family).   Amount Provider Charged   This column lists the amount of the charge the provider 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.   Medicare -Approved Amount   This column lists the amount that Medicare allows for the 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.   Medicare Paid You   This column lists the amount that Medicare paid the beneficiary toward the unassigned 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 ite m.  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 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.  Note indicators use capital letters, and indicators should be printed in alphabetic order, with a comma without space preceding each indicator after the first indicator for a line (e.g., A,B,C). Show no more than three alphabetic indicators per line.  If more than three indicators are required, print on the next line below.  A maximum of five notes are allowed per service, so no more than five note indicators should ever be listed here.   If the same message is needed for more than one claim or service line on a single page, print the same alphabetic code each time the message is required on that page.  If, however, that sa me message is required on a following page, use a new indicator letter in the appropriate alphabetical order for that page.   Continue alphabetical order from page to page - do not restart the alphabet on each new page.   If more than 26 alphabetic codes are  needed, begin using lowercase alphabetic codes (e.g., a,b,c). If more than 52 alphabetic codes are needed, repeat using capital letters.   Multiple Dates Subtitles   If a single claim includes services provided on multiple dates, then a dynamic date subtitle should be introduced into the claim body, separating the individual claim items into clusters by date.  See Exhibit 2.6 for examples of claims with these various options for dynamic column subtitles.  Any subtitle should run across the full width of the claim columns, but the dynamic content is placed only in the first column.  The preference is for each individual day to be given a separate subtitle, with claim items grouped just by that one date.  The date subtitle clusters should then be listed chronol ogically, earliest first.  If the claims data for an item only includes a range, then that claim item can be listed under a range header, which should be sorted chronologically by its start date.  The date format follows the same conventions outlined above  in the Claim Header subsection.   CONTENT   {Service description} ({Revenue Code})  Yes [or] NO [or] Yes -  adjusted  [or]  NO - adjusted  ${###,###.##} ${###,###.##} ${###,###.##} ${###,###.##}  {NOTE INDICATOR(S)}   F. Claim Total Line   The Claim Total Line subsection is the default subsection to follow the Claim Content Lines subsection.  If a single claim is splitting across pages, suppress this subsection and replace with the continuation footer instead.  Each claim will have only one instance of claim total line. Reference section I. Breaking Claims -  Continuation Footer for specifications regarding the alternate option.   POSITION   This subsection is directly after the claim content lines subsection with fixed content area.  It is full- page or 540 points i n width and 21 points in height.  There are six columns.  The five right -most columns correspond to the columns 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.   PART A INPATIENT SPECIFICATIONS   See Exhibit 1.1 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:  (blank)  Column 4:  [TB 2.1] non- covered 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 both sides and the bottom 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 control number for the claim, preceded by a static text phrase:   Total for Claim #{Claim Number}   Insert dashes in the control number as indicated by the system.   Total of Non -Covered Charges   This column lists the sum of the line -item amounts above for any claim charges that Medicare did not cover.  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 that Medicare paid toward the claim. This figure may be up to eight digits long, including c ents:   ${###,###.##}  Insert a comma between the thousands digit and the hundreds digit of any four -figure or higher amount.  Use $0.00 for zero.  If the field has more than 11 characters, replace with see note and list the amount in the notes.  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.  If the field has more than 11 characters, replace with see note and list the amount in the notes.  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.  A maximum of six notes are allowed per total line.   CONTENT   Total for Claim #{Claim Number}  ${###,###.##} ${###,###.##} ${###,###.##}  {NOTE INDICATOR(S)}   HOSPICE AND HOME HEA LTH SPECIFICATIONS   See Exhibit 1.3 and Exhibit 1.4 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 d ashes in the claim number as indicated by the system.   Total Amount Provider Charged   This column lists the sum of the line -item amounts above of the charges the provider 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.  If the field has more than 11 characters, replace with see note and list the amount in the notes.  Total Medicare -Approved Amount   This column lists the sum of the line -items amounts above for what Medicare allows for the 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.  If the field has more than 11 characters, replace with see note and list the amount in the notes.  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.  If the field  has more than 11 characters, replace with see note and list the amount in the notes.  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 u p 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.  If the field has more than 11 characters, replace with see note and list the amount in the notes.   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 Con tent Lines specifications for detailed instructions.  A maximum of six notes are allowed per total line.   CONTENT   Total for Claim #{Claim Number}  ${###,###.##} ${###,###.##} ${###,###.##} ${###,###.##}  {NOTE INDICATOR(S)}   PART B ASSIGNED SPEC IFICATIONS   See Figure 10.3.6.F2 and Exhibit 1.5 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, rig ht 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: