Check Format Specifications - (Rev. 5, 08-30-02)

30.4 - Check Format Specifications - (Rev. 5, 08-30-02) A1-1403.4, B1-4403.4, B2-5215 The following phrase must appear on all checks or drafts written for purposes of paying benefits and related administrative costs authorized under the Medicare program: MEDICARE PAYMENT For Health Insurance - Social Security Act The contractor shall use the following check format specifications: Check Front The contractor shall center the words "Medicare Payment" at the top of the check or draft and print these words in at lease 1/4-inch type. Contractor name and address should appear on the face of the check. The check may also include the contractor's emblem or a picture of a building it occupies. The contractor may not include advertising on the face of the check. (Advertising should not appear on the envelope in which the check is mailed.) It is expected that the type sizes of the items placed on the check will not detract from the required "Medicare Payment" phrase. Check Back The contractor shall print on the back of all Medicare checks the following statement: "This payment is made with Federal funds. Fraud in procuring, forging a signature or endorsement, or materially altering this check is punishable under the U. S. Criminal Code." For carriers, assigned claims must also include the following statement: "As provided by the terms of the law under which this check is issued, the undersigned payee, in accepting assignment, agreed that the charge determination by the Medicare carrier shall be the full charge for any service which the check is payable. The patient is responsible only for the applicable deductible and coinsurance, and for non-covered services." It is not necessary to show the account name on the check. If one is shown, it should read "Federal Health Insurance Benefits Account." If both Part A and Part B are shown, it should read, "Federal Health Insurance Benefits Account - Part A" and "Federal Health Insurance Benefits Account - Part B." The time limitation for cashing the check (if specified on the check) cannot be less than 6 months. The contractor shall clear formats of checks with the servicing RO prior to printing or contracting for printing.