CMS Pub. 100-04, ch. 21, § 10.3.11

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.