CMS Pub. 100-04, ch. 3, § 180.2

Care Determinations by the Non-specialty Contractor

(Rev. 2654, Issued: 02-08-13, Effective: 05-09-13, Implementation, 05-09-13)

Beneficiaries are informed of all Medicare payment determinations, including those for

RNHCI services, via their monthly Medicare Summary Notice (MSN). The complete set

of messages used on the MSN can be found in chapter 21, section 50.42 of this manual.

Non-specialty contractors use special messages on MSNs to reflect determinations

specific to excepted or nonexcepted care.

• If a determination of excepted care is made, the non-specialty contractor uses MSN

message 42.1. This message reads: “You received medical care at a facility other

than a religious nonmedical health care institution but that care did not revoke your

election to receive benefits for religious nonmedical health care.”

• If a determination of nonexcepted care is made, the non-specialty contractor uses

MSN message 42.2. This message reads: “Since you received medical care at a

facility other than a religious nonmedical health care institution, benefits for

religious nonmedical health care services has been revoked for these services

unless you file a new election.”

If development to make the excepted/nonexcepted care determination discovered that the

beneficiary did not request Medicare payment, but instead paid for the services out of

pocket, the non-specialty contractor uses MSN message 16.41. This message reads:

“Payment is being denied because you refused to request reimbursement under your

Medicare benefits.”