Specifications for RRB Specialty MAC MSNs

10.3.11 - Specifications for RRB Specialty MAC MSNs (Rev. 3210, Issued: 03-03-15, Effective: 04-16-15. Implementation: 04-16-15) RRB Specialty MAC (S MAC) MSNs produced by Palmetto GBA will follow the design Specifications for the Medicare MSNs. Since RRB is an independent Federal agency, the DHHS seal and Medicare contact numbers/website will be replaced by appropriate content for RRB. Exceptions are noted below. See Exhibit 1.9 for an example of RRB S MAC MSN in English and Exhibit 3.9 for RRB S MAC MSN in Spanish. The envelope design and watermark on paper from previous RRB Part BS MAC MSN design will be used as is. A. Notice Title (10.3.3.A) Replace RRB logo and descriptive tagline. [The below figure is new.] FORMATTING [GL 9] RRB logo [TH 1.1] notice title [TH 1.2] notice subtitle, indicating to which Medicare program the notice relates [GR 8] space after Notice title [TB 3] notice descriptive tagline CONTENT Notices with only claims paid by the RRB S MAC program should have text content as follows: Medicare Summary Notice for Part B (Medical Insurance) The Official Summary of Your Medicare Claims from the RRB Specialty Medicare Administrative Contractor B. Foreign Language Footer (10.3.3.J) Replace 1-800-MEDICARE with RRB’s contact number. [The below figure is new.] FORMATTING [GL 2-RRB] foreign-language footer C. How to Report Fraud (10.3.4.C) Replace 1-800-MEDICARE with RRB’s contact number. [The below figure is new.] CONTENT How to Report Fraud If you think a provider or business is involved in fraud, call us at 1-800-833-4455. Some examples of fraud include offers for free medical services or billing you for Medicare services you didn’t get. If we determine that your tip led to uncovering fraud, you may qualify for a reward. {CMS fraud message of 185 characters (four lines of text) The first sentence may be bold, while the remaining text is regular, with occasional bits, such as monetary figures or important words, highlighted in bold.} D. How to Get Help with Your Questions (10.3.4.D) Replace 1-800-MEDICARE with RRB’s contact number. [The below figure is new.] CONTENT How to Get Help with Your Questions 1-800-833-4455 Your customer-service code is {5-DIGIT S MAC ID CODE}. Representatives are available 8:30 a.m. until 7 p.m. Eastern Time, Monday through Friday. TTY 1-877-566-3572 (for hearing impaired) Contact your State Health Insurance Program (SHIP) for free, local health insurance counseling. Call {10-DIGIT PHONE NUMBER FOR SHIP IN RECIPIENT’S STATE OF RESIDENCE}. Or, if the MSN mailing address is outside the 50 U.S. states and U.S. territories: How to Get Help with Your Questions 1-800-833-4455 Your customer-service code is {5-DIGIT S MAC ID CODE}. Representatives are available 8:30 a.m. until 7 p.m. Eastern Time, Monday through Friday. TTY 1-877-566-3572 (for hearing impaired) E. Get More Details (10.3.8.B) Replace 1-800-MEDICARE with RRB’s contact number. [The below figure is new.] 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 didn’t, 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 1-800-833-4455 for more information about a coverage or payment decision on this notice, including laws or policies used to make the decision. F. If You Need Help Filing Your Appeal (10.3.8.D) Replace 1-800-MEDICARE with RRB’s contact number. [The below figure is new.] CONTENT If You Need Help Filing Your Appeal Contact us: Call 1-800-833-4455 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 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 U.S. states and U.S. territories, use the following language: If You Need Help Filing Your Appeal Contact us: Call 1-800-833-4455 for help before you file your written appeal, including help appointing a representative. Call your provider: Ask your provider 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. G. Find Out More (10.3.8.E) Replace Medicare’s website with Palmetto’s website. [The below figure is new.] CONTENT Find Out More About Appeals For more information about appeals, read your “Medicare & You” handbook or visit us online at http://www.palmettogba.com/rr/me.