Medicare Claims Processing Manual (Pub. 100-04), Ch. 21 § 10.3.4
Specifications for Header for Other Pages
10.3.4 - Specifications for Header for Other Pages
(Rev. 2522, Issued: 08-21-12, Effective: 07-01-12 (Analysis and Design) 10-01-12
(Final Design Testing) 01-03-13(Final Implementation), Implementation: 07-01-12
(Analysis and Design) 10-01-12 (Final Design Testing) 01-03-13(Final
Implementation)
This element repeats at the top of every page of the MSN, except for the first page. It
contains the beneficiary’s name, a notification, and page numbering.
POSITION
This subsection is of a fixed size. It does not vary in overall width or length.
It begins (0˝, 0˝) and is full-page or 540 points in width.
The first content unit, the beneficiary’s name, is flush left. The second content unit,
containing the notification text and page numbering, is flush right.
FORMATTING
[TB 2.2] beneficiary name
[TB 2.2] “This Is Not a Bill”, all caps, right aligned
[TB 2.1] ”|”, then page number, right aligned
DYNAMIC RULES
This section contains two dynamic elements, the beneficiary’s name and the page
numbering.
The beneficiary’s name should be printed with the given name first, followed by any
middle initial(s), the family name, then any suffixes (e.g., Jr.)
The page number indicator, in the format {Page # of #}, must include the number of the
page on which the element appears and, in the second numeric position, the total page
count for the notice.
CONTENT
{Beneficiary’s Given Name}{Beneficiary’s Middle Initials}{Beneficiary’s Family
Name}{Beneficiary’s Suffix}
THIS IS NOT A BILL | {Page # of #}