(Medicare Claims Processing Manual)

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:   ${###,###.##}  Insert a comma between the thousands digit and the hundreds digit of any f our-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 same 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.   CONTENT   {Inpatient hospital benefit period starting Month DD, YYYY} [or] {Skilled nursing facility benefit period starting Month DD, YYYY}   1 day [or] {#} days [or] none remain  Yes [or] NO [or] Yes -  adjusted [or]  NO - adjusted  ${###,###.##} ${###,###.##} ${###,###.##}  {NOTE INDICATOR(S)}   or  [blank]  none  Yes [or]  NO [or] Yes -  adjusted [or]  NO -  adjusted  ${###,###.##} ${###,###.##} ${###,###.##}  {NOTE INDICATOR(S)}   HOSPICE SPECIFICATIO NS  See Exhibit 1.3 for layout reference.     FORMATTING   [GR 3.2] dotted line [GR 2.2] black rule   Column 1:  [TB 2.2] quantity and level of care description, left aligned  or [TB 2.] quantity and service visit description, left aligned  Column 2:  [TB 2.1] approved status for level of care, right aligned  Column 3:  [TB 2.1] amount charged for level of care, right aligned  Column 4:  [TB 2.1] amount approved for level of care, right aligned  Column 5:  [TB 2.1] amount paid for level of care, right aligned, with 5 point indent  Column 6:  [TB 2.2] maximum for level of care, right aligned, with 3.5 point indent  Column 7:  [TB 2.2] note indicator for level of care, left aligned, with 5 point indent   NOTE:  Columns 2 through 7 should be filled only for level of care.  They should be left blank for service visit lines.  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 sides only.   NOTE:  Between level of care and service visit lines, insert [GR 5] 7 point space in between the claim lines.  There is no dotted lin e in between.   DYNAMIC RULES   The content in this section is entirely dynamically generated.  It includes the following content elements:   Quantity & Service Provided   This column should contain the quantity or number of level of care provided, followed by  the description of the level of care provided in bold.  Then items below should contain the quantity or number of service visit provided, followed by the description of the service visit provided. There may be multiple service visit types per one level of  care.   Whenever possible, the number of level of care and service visit provided should be expressed as a whole number, without decimal point or trailing zero (e.g. 2, not  2.0).  Only if the number is a partial quantity, then include a decimal point and a  fractional amount, rounded to the nearest tenth (e.g. 2.5, not 2.49).  Use the most -recent level of care and service visit descriptions. Suppress the billing code.   Service Approved?   This column indicates if a claim item was approved or denied. It also i ndicates 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.  Amount Provider Charged   This column lists the amount of the charge the provider submitted.  This figure field has a maximum of 11 characters, 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 amo unt that Medicare allows for the service.  This field has a maximum of 11 characters, 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 Med icare Paid   This column lists the amount that Medicare paid toward the claim.  This field has a maximum of 11 characters, 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 field has a maximum of 11 characters, 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 appli cable.   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 six notes are allowed per service, so no more than six 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 same 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 le tters.   CONTENT   {Level of care description} {Service visit description}  Yes [or]  NO [or] Yes -  adjusted [or]  NO -  adjusted  ${###,###.##} ${###,###.##} ${###,###.##} ${###,###.##}  {NOTE INDICATOR(S)}   HOME HEALTH SPECIFIC ATIONS   See Exhibit 1.4 for layout reference.     FORMATTING   [GR 3.2] dotted line [GR 2.2] black rule  Column 1:  [TB 2.1] quantity and service description, 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, 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   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 sides only.   NOTE:  When there is more than one service line, format [GR 3.3] dotted rule 3 in between the claim lines.   NOTE:  For multiple dates and/or providers subtitles, insert the following before corresponding service lines(s):   [TH 5.1] date or provider information [GR 3.3] dotted rule 3  See Exhibit 2.6 for examples of claims with these various options for dynamic column subtitles.   DYNAMIC RULES   The content in this section is entirely dynamically generated.  It includes the following content elements:   Quantity & Service Provided   This column should contain the quantity or number of services provided, followed by the description of the service provide d.  Whenever possible, the number of services provided should be expressed as a whole number, without decimal point or trailing zero (e.g. 2, not  2.0).  Only if the number is a partial quantity, then include a decimal point and a fractional amount, rounded to the nearest tenth (e.g. 2.5, not 2.49).  Use the most recent consumer -friendly HCPCS (level 1)/CPT service descriptions, which can be found on the CMS systems mainframe or at https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html .  The service description has a maximum of 100 characters.  Suppress the rest if the description runs longer.   Servi ce 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.   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 item.  This figure may be up to eight digits long, including cents:   ${###,###.##}