Basic Concepts and Approaches

10.3.1 - Basic Concepts and Approaches (Rev. 3210, Issued: 03-03-15, Effective: 04-16-15. Implementation: 04-16-15) A. Overview The Medicare Summary Notice (MSN) is a printed notification, sent to Medicare beneficiaries enrolled in Original Medicare, that displays data for claims processed during a given reporting period. The MSN lists claim information in a summarized format. It also contains other helpful information for beneficiaries. Each MSN consists of the following four sections: SECTION 1: SUMMARY (PAGE 1) A one-page summary of the beneficiary’s Medicare status and of the claims’ data on the notice. SECTION 2: MAKING THE MOST OF YOUR MEDICARE (PAGE 2) One page with tips for beneficiaries on how to use their MSN, get help with Medicare issues, and learn more about Medicare services. SECTION 3: CLAIMS (PAGE 3 - X) A section, which may extend over multiple pages, listing the beneficiary claims submitted to Medicare over the period of the notice. SECTION 4: DENIALS & APPEALS (LAST PAGE) One page containing details on beneficiaries’ appeals rights and, more generally, on how they can get help with denied claims. Layout and content specifications for these sections begin at §10.3.4. Specifications address the position, formatting, content, and (if applicable) rules for dynamic content in individual subsections of each section. B. Claim Types: The ‘Extended Family’ of MSNs Medicare claims are processed and paid under a range of different systems. (In addition, different claim types may be processed and printed by separate MACs.) While the overall appearance and format of all MSNs is consistent, different claim types do require some variations in the notice, in both the type of content supplied and the specific language used. This document identifies eight primary claim types in the “extended family” of MSNs: GLOBAL NOTICE: This file version does not include specifications for Part A claims for inpatient mental health care in a psychiatric hospital. The instructions for these claims will be included in a subsequent version. • Part A Inpatient Claims for inpatient hospital services and skilled-nursing facility services. • ‘B of A’ Claims for outpatient services provided by medical facilities; these claims are paid under the Part B program, but their claim data is presented in a format similar to Part A Inpatient claims. • Hospice Claims for hospice care, which are paid for under Part A but require a claim format more similar to Part B claims. • Home Health Claims for home-health services that are paid under Part A or Part B. These MSNs also require a claim format more similar to Part B claims. • Part B, unassigned Claims for Part B medical services from providers that do not accept Medicare assignment; payment for unassigned claims may be made directly to beneficiaries, which affects the format of claims data on the MSN. • DME, assigned Claims for durable medical equipment (DME) and related services from suppliers that accept Medicare assignment. • DME, unassigned Claims for DME from suppliers that do not accept Medicare assignment; payment for unassigned claims may be made directly to beneficiaries, which affects the format of claims data on the MSN. COMBINED MSNs In some instances, multiple claim types may be combined on a single MSN. This most commonly occurs with Part A Inpatient and ‘B of A’ claims, with Part B assigned and unassigned claims, and with DME assigned and unassigned claims. Instructions related to combined MSNs will be found below in any section or subsection that is affected. PAY MSNs From time to time, beneficiaries may receive an MSN that includes a check, refunding an overpayment made (most often) for Part B services, either assigned or unassigned. Instructions related to Pay MSNs will be found below in any section or subsection that is affected. Instructions for the check cover sheet are located near the rear of this chapter. Instructions for Pay MSN envelopes are located in the Envelopes section. In addition, there are examples of complete Pay MSNs in the Exhibits section. EFFECT OF CLAIM TYPES In the specifications below, layout and content instructions can be assumed to be global - that is, they apply to all MSNs, regardless of what types of claims appear on the notice. However, there are particular sections and subsections of the MSN where the type of claims on the MSN determines not only what specific claim data is printed, but also affects the inclusion of other content and language across the notice. If a given subsection is affected by the claim type(s) on the notice, specifications for that subsection will be split - into global specifications and specifications for each member of the extended family.