CMS Pub. 100-04, ch. 21, § 10.3.3

A. Notice Title

This section names the notice, specifies the function of the notice and the Medicare

program under which the notice’s claims are paid, and identifies the Federal agencies

responsible for generating the notice.

GLOBAL SPECIFICATIONS

POSITION

This subsection contains information of a fixed size. It does not vary in overall width or

length.

The content area begins (0˝, 0˝), and is full page or 540 points in width, 72 points in

height.

The Department of Health & Human Services seal, a flash image, is 72 points by 72

points. Indent 9 points from the seal to start the three text elements.

MACs are not to change the format of the Notice Title subsection in order to use double

window envelopes.

FORMATTING

[GL 1] DHHS Seal

[TH 1.1] notice title

[TH 1.2] notice subtitle, indicating to which Medicare program the notice relates

[TB 3] notice descriptive tagline

NOTE: Pagination specification on next subsection

NOTE: Use [TH 1.3] or [TH1.4] instead of [TH 1.2] for combined subtitle to fit in one

line.

NOTE: Use [TH 1.4] only if using [TH 1.3] for combined subtitle will not fit in one line.

DYNAMIC RULES

The notice subtitle is dynamically generated based on which type(s) of claims are present

on the MSN:

• Only claims paid by the Part A program;

• Part B, ‘B of A’, or DME claims - all of which are paid by the Part B program; or

• A combination of Part A Inpatient and ‘B of A’ claims that are paid by both Part

A and Part B.

PART A INPATIENT, HOSPICE, AND HOME HEALTH (A) SPECIFICATIONS

CONTENT

Notices with only claims paid by the Part A program should have text content as follows:

Medicare Summary Notice

for Part A (Hospital Insurance)

The Official Summary of Your Medicare Claims from the Centers for Medicare &

Medicaid Services

PART B (ASSIGNED & UNASSIGNED), HOME HEALTH (B), ‘B OF A’, AND

DME SPECIFICATIONS

CONTENT

Notices with only claims paid by the Part B program should have text content as follows:

Medicare Summary Notice

for Part B (Medical Insurance)

The Official Summary of Your Medicare Claims from the Centers for Medicare &

Medicaid Services

COMBINED PART A INPATIENT AND ‘B OF A’ SPECIFICATIONS

CONTENT

Notices that include both claims paid by the Part A program and also claims paid by the

Part B programs - as on notices that have both inpatient hospital claims and outpatient ‘B

of A’ claims - should have text content as follows:

Medicare Summary Notice

for Part A (Hospital Insurance) and Part B (Medical Insurance)

The Official Summary of Your Medicare Claims from the Centers for Medicare &

Medicaid Services

B. Pagination

The page number indicator, in the format Page 1 of #, must include the dynamically

generated total page count for the notice in the second numeric position. Refer to

specimen on section A for type style and placement relative to Notice title.

NOTE: This specification is for pagination on page 1 only. See section 10.3.4 for

pagination included on page header for other pages.

POSITION

This subsection contains information of a fixed size. It does not vary in overall height but

may vary in width depending on total page count.

The content area begins (0˝, 6.75˝), right aligned from right margin. It is 90 points in

width, 11 points in height.

FORMATTING

[TB 2.1] all text, right aligned

C. Recipient Address

POSITION

This subsection contains information of a variable size.

The content area begins (0˝, 1.35˝) with 32 point indent from left margin. It is 1-column

or 259 points in width with variable height, from 3 to 6 lines of text, not to exceed 82

points at 6 lines.

The name and address information is listed with 9-point clearance around the address

when inserted into window envelope, to meet U.S. Postal Service regulations. For

specifications on window size and position, see section 10.3.10.

The position may vary for envelope to align with the recipient address of the inserted

MSN. Depending on the alignment, the address field of the printed MSN may be adjusted

for ideal positioning.

[The below figure is new.]

FORMATTING

[TB 1.1] all text, all caps

NOTE: MACs may also use a smaller font size [TB 1.3] or [TB 1.4] if needed.

DYNAMIC RULES

All of the content in this subsection is dynamically generated.

At minimum, the beneficiary name and one- or two-line mailing address should be

printed. The name should be printed with the given name first, followed by any middle

initial(s), the family name, then any suffixes (e.g., Jr.)

If applicable, when the beneficiary’s primary residence is a healthcare facility, a facility

name may be appended above the beneficiary’s name.

As necessary, a second name (the beneficiary’s legal representative) may be added above

the beneficiary’s name, followed by “for”. The name should be printed in bold with the

given name first, followed by any middle initial(s), the family name, then any suffixes

(e.g., Jr.)

In the case that a legal representative is indicated, the designated recipient’s mailing

address (if different from the beneficiary’s address) should be used instead of the

beneficiary’s address.

The hierarchy of address should be as follows:

• Legal representative

• Beneficiary’s temporary address

• Beneficiary’s permanent address

CONTENT

{BENEFICIARY’S GIVEN NAME}{BENEFICIARY’S MIDDLE

INITIAL}{BENEFICIARY’S FAMILY NAME}{BENEFICIARY’S SUFFIX}

{PERMANENT STREET ADDRESS}

{SECOND LINE OF STREET ADDRESS}

{CITY}, {STATE ABREVIATION} {ZIP+4}

Or

{BENEFICIARY’S GIVEN NAME}{BENEFICIARY’S MIDDLE

INITIAL}{BENEFICIARY’S FAMILY NAME}{BENEFICIARY’S SUFFIX}

{TEMPORARY ADDRESS FACILITY NAME OR STREET ADDRESS}

{SECOND LINE OF STREET ADDRESS}

{CITY}, {STATE ABREVIATION} {ZIP+4}

Or

{LEGAL REPRESENTATIVE’S GIVEN NAME}{LEGAL REPRESENTATIVE’S

MIDDLE INITIALS}{LEGAL REPRESENTATIVE’S FAMILY NAME}{LEGAL

REPRESENTATIVE’S SUFFIX} FOR

{BENEFICIARY’S GIVEN NAME}{BENEFICIARY’S MIDDLE

INITIAL}{BENEFICIARY’S FAMILY NAME}{BENEFICIARY’S SUFFIX}

{LEGAL REPRESENTATIVE’S STREET ADDRESS}

{SECOND LINE OF STREET ADDRESS}

{CITY}, {STATE ABREVIATION} {ZIP+4}

NOTE: Comma between City and State is optional, to follow current practice.

D. Notice Details

This subsection provides a summary of whom the notice is for and what time period it

covers.

POSITION

This subsection has a fixed size and position.

The subsection is printed on a gray highlight box. The gray area begins (0˝, 2.75˝). It is

one-column or 259 points in width and 108 points in height.

Indent in 8 points all around to begin content area.

The three lines of body content are organized into static and dynamic text. Static text is

in regular text, without changing content. Indent 133 points in from left margin to start

dynamic text (e.g., beneficiary’s Medicare number) in bold.

FORMATTING

[GR 1] gray background

[TH 3] notice details header

[GR 4.1] spacing after header

[GR 3.1] dotted rule

[TB 2.1] static body content [TB 2.2] dynamic body content

[GR 3.1] dotted rule

[TB 2.1] static body content [TB 2.2] dynamic body content

[GR 3.1] dotted rule

[TB 2.1] static body content [TB 2.2] dynamic body content

DYNAMIC RULES

This subsection is comprised of four lines; each line has both static and dynamic content.

Notice for…

The first line has the static text “Notice for” followed by the beneficiary’s given and

family names. Note that for space purposes the middle initial(s) and suffixes should not

be included here.

Medicare Number

The second line has a static title and the beneficiary’s Medicare number.

When possible, the number should be broken by dashes in the format (e.g., 1EG4-TE5-

MK72).

Date of This Notice

The third line has a static title and the date that the notice was printed. The date is listed

with a spelled-out month, numeric day, and complete numeric year (e.g., October 15,

2021).

Claims Processed…

On a typical MSN, the fourth line has a static title, “Claims Processed Between” and

dates that represent the start and end dates of the complete claim-processing period. The

first date printed should correspond to the first day of the period that was reviewed for

claims prior to the generation of the notice. The final date printed should reflect the final

day that was reviewed for claims prior to the printing of the notice. This period typically

spans an entire 90-day period prior to the printing of the notice. (Note that this is not the

same as the processing dates of the first- and last-processed claims on the notice, which

may cover a much shorter period.)

The dates are listed with a spelled-out month, numeric day, and complete numeric year

(e.g., October 15, 2021) and are separated by an en-dash (not a hyphen); insert spaces to

each side of the en-dash. If both the first and last date are within the same calendar year,

drop the year from the first date (e.g., October 15 - November 3, 2021). If the dates are

in different calendar years, keep the year in both dates (e.g., October 15, 2021 - January

3, 2022).

NOTE: When printing a Pay MSN or other MSN with a single processing date, replace

static text “Claims Processed Between” with the label “Claims Processed”; on an MSN of

this kind, only the single processing date should be listed, following the formatting

conventions described above.

CONTENT

Notice for {Beneficiary Given Name}{Beneficiary Family Name}

Medicare Number {XXXX-XXX-MK72}

Date of This Notice {Month DD, YYYY}

Claims Processed {Month DD, YYYY} -

Between {Month DD, YYYY}

Or, if the notice is a Pay MSN or an MSN with a single processing date, use the

following:

Notice for {Beneficiary Given Name}{Beneficiary Family Name}

Medicare Number {XXXX-XXX-MK72}

Date of This Notice {Month DD, YYYY}

Claims Processed {Month DD, YYYY}

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 #}