CMS Pub. 100-04, ch. 21, § 10.3.8

This section of the MSN helps beneficiaries understand how to handle

denied claims; it also explains how and when to file an appeal. This section

should be printed in its entirety on exactly one page, and it should always

appear on the MSN’s final page. It can appear on either the front or reverse

of a sheet.

A. Section Title

POSITION

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

overall width or length.

The content area begins (0˝, 5˝), 7 points from the baseline of Headers of

Other Pages subsection. It is full-page or 540 points in width and 24 points in

height.

FORMATTING

[GR 2.1] black rule

[TH 2] section header

DYNAMIC RULES

N/A - this section is static

CONTENT

How to Handle Denied Claims or File an Appeal

B. Get More Details

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˝, 0.94˝) or 28 points from the baseline of the

Section Title subsection. It is one-column or 259 points in width and 167

points in height.

FORMATTING

[GR 2.1] black rule

[TH 3] subsection header

[GR 4.1] space after header

[TB 1.2] highlight first sentence [TB 1.1] body text

[GR 6] space between paragraph

[TB 1.1] body text

DYNAMIC RULES

N/A - this section is static

PART A INPATIENT AND ‘B OF A’ SPECIFICATIONS

CONTENT

Get More Details

If a claim was denied, call or write the hospital or facility and ask

for an itemized statement for any claim. Make sure they sent in the

right information. If they didn’t, ask the facility to contact our claims

office to correct the error. You can ask the facility for an itemized

statement for any service or claim.

Call 1-800-MEDICARE (1-800-633-4227) for more information about a

coverage or payment decision on this notice, including laws or policies

used to make the decision.

PART B (ASSIGNED AND UNASSIGNED), HOSPICE, AND HOME

HEALTH

SPECIFICATIONS

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-MEDICARE (1-800-633-4227) for more information about a

coverage or payment decision on this notice, including laws or policies

used to make the decision.

DME (ASSIGNED AND UNASSIGNED) SPECIFICATIONS

CONTENT

Get More Details

If a claim was denied, call or write the supplier and ask for an

itemized statement for any claim. Make sure they sent in the right

information. If they did not, ask the supplier to contact our claims office

to correct the error. You can ask the supplier for an itemized statement

for any item or claim.

Call 1-800-MEDICARE (1-800-633-4227) for more information about a

coverage or payment decision on this notice, including laws or policies

used to make the decision.

C. If You Disagree

POSITION

The position of this subsection is dynamic. The content area begins 19

points from the baseline of the Get More Details subsection. It is one-column or 259 points in width and 132 points in height. The last line has a

black rule around the appeal due date. The date field is 158 points wide.

Formatting

[GR 2.1] black rule

[TH 3] subsection header

[GR 4.1] space after header

[TB 1.2] highlight first sentence [TB 1.1] body text

[GR 6] space between paragraph

[TB 1.1] body text

[TB 1.2] appeals due date, center aligned [GR 2.2] highlight edges of

Column 2

DYNAMIC RULES

This subsection contains a dynamically generated date: the beneficiary’s

appeal deadline. The date printed should be 125 days from the notice date in

the Notice Details subsection of Part 1. The date is listed with a spelled-out

month, numeric day, and complete numeric year (e.g., October 15, 2021).

CONTENT

If You Disagree with a Coverage Decision, Payment Decision, or

Payment Amount on this Notice, You Can Appeal

Appeals must be filed in writing. Use the form to the right. Our

claims office must receive your appeal within 120 days from the date

you get this notice.

We must receive your appeal by:

{Month DD, YYYY}

D. If You Need Help Filing Your Appeal

GLOBAL SPECIFICATIONS

POSITION

The position of this subsection is dynamic. The content area begins 19

points from the baseline of the If You Disagree subsection. It is one-column

or 259 points in width and 190 points in height.

FORMATTING

[GR 2.1] black rule

[TH 3] subsection header

[GR 4.1] space after header

[TB 1.2] highlight first sentence [TB 1.1] body text

[GR 6] space between paragraph

[TB 1.2] highlight first sentence, [TB 1.1] body text

[GR 6] space between paragraph

[TB 1.2] highlight first sentence [TB 1.1] body text

DYNAMIC RULES

If the mailing address is that of the legal representative, the beneficiary’s

address state should be used to identify the SHIP contact number, not that of

the legal representative.

NOTE: If the mailing address is that of the legal representative and the

beneficiary’s address indicates that the beneficiary lives outside of the 50

U.S. states and U.S. territories, then the final paragraph on page 2 should be

suppressed. See alternate language in the Content specifications below.

When there is a combined MSN that has Part A Inpatient claims with

Hospice and/or Home Health claims, use the content for Part A Inpatient

specification.

PART A INPATIENT AND ‘B OF A’ SPECIFICATIONS

CONTENT

If You Need Help Filing Your Appeal

Contact us: Call 1-800-MEDICARE or your State Health Insurance

Program (see page 2) for help before you file your written appeal,

including help appointing a representative.

Call your facility: Ask your facility 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 states, use the following

language:

If You Need Help Filing Your Appeal

Contact us: Call 1-800-MEDICARE for help before you file your

written appeal, including help appointing a representative.

Call your facility: Ask your facility 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.

PART B (ASSIGNED AND UNASSIGNED), HOSPICE, AND HOME

HEALTH

SPECIFICATIONS

CONTENT

If You Need Help Filing Your Appeal

Contact us: Call 1-800-MEDICARE 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 states, use the following

language:

If You Need Help Filing Your Appeal

Contact us: Call 1-800-MEDICARE for help before you file your

written appeal, including help appointing a representative.

Call your facility: Ask your facility 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.

DME (ASSIGNED AND UNASSIGNED) SPECIFICATIONS

CONTENT

If You Need Help Filing Your Appeal

Contact us: Call 1-800-MEDICARE or your State Health Insurance

Program (see page 2) for help before you file your written appeal,

including help appointing a representative.

Call your supplier: Ask your supplier 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 states, use the following

language:

If You Need Help Filing Your Appeal

Contact us: Call 1-800-MEDICARE for help before you file your

written appeal, including help appointing a representative.

Call your facility: Ask your facility 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.

E. Find Out More

POSITION

The position of this subsection is dynamic. The content area begins 19

points from the baseline of the If You Need Help Filing Your Appeal

subsection. It is one-column or 259 points in width and 72 points in height.

FORMATTING

[GR 2.1] black rule

[TH 3] subsection header

[GR 4.1] space after header

[TB 1.1] body text

CONTENT

Find Out More About Appeals

For more information about appeals, read your “Medicare & You”

handbook, or visit us online at www.medicare.gov/appeals.

F. File an Appeal in Writing

GLOBAL SPECIFICATIONS

POSITION

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

overall width or length.

This subsection begins (3.9˝, 0.94˝). This should top align with the Get

More Details subsection in the left column. It is one-column or 259 points

in width and 652 points in height.

Indent in 8 points top and left and 16 points from right to begin content area.

Tab 12 points from left to start appeal instructions and fill-in box.

The beneficiary fill-in box in Step 3 is 218 points in width and 22 points in

height.

The telephone number fields are split further, with 19 points of width for

each number and 7 points of space in between the fields. Any space after the

10 digit fields should be left as gray fill.

Revised figure 10.3.8.F

FORMATTING

[GR 1] gray fill

[TH 3] subsection header

[GR 4.1] space after header

[TB 2.1] body text

[GR 4.1] space after header

[TB 2.2] step 1 [TB 2.1] body text

[GR 4.1] space after header

[TB 2.2] step 2 [TB 2.1] body text

[GR 4.1] space after header

[TB 2.2] step 3 [TB 2.1] body text

[GR 4.1] space after header

[TB 2.1] fill in category

[GR 5] space after text

[GL 7] fill in box

[GR 6] space after text

[TB 2.1] fill in category

[GR 5] space after text

[GL 7] fill in boxes

[GR 4.1] space after header

[TB 2.2] steps 4 - 7 [TB 2.1] body text

[GR 4.1] space after header

[TB 2.2] MAC address

DYNAMIC RULES

In Step 7 of the File an Appeal in Writing subsection, beneficiaries are

instructed where to mail their appeals material. The mailing address listed

should be the preferred mailing address of the MAC generating the MSN.

The address should appear in the following format:

First Line: Medicare Claims Office (static text)

Second Line: c/o { A/B MAC (A), (B), (HHH), or DME MAC

Name} Third Line: { MAC Street Address or PO Box,

Suite Number}

Fourth Line: { MAC City}, {ST} {ZIP+4}

If the MAC uses another name to refer to the ‘Medicare Claims Office,’ add

an additional line after the second line with an ‘attn:’ to refer to the

department. The first line should stay static for all return addresses.

First Line: Medicare Claims Office (static text)

Second Line: c/o {A/B MAC (A), (B), (HHH), or DME MAC Name}

Third Line: attn: {Appeals Department Name}

Fourth Line: {MAC Street Address or PO Box, Suite Number}

Fifth Line: {MAC City}, {ST} {ZIP+4}

When there is a combined MSN that has Part A Inpatient claims with

Hospice and/or Home Health claims, use the content for Part A Inpatient

specification.

PART A INPATIENT AND ‘B OF A’ SPECIFICATIONS

CONTENT

File an Appeal in Writing

1 Circle the service(s) or claim(s) you disagree with on this

notice.

2 Explain in writing why you disagree with the decision.

Include your explanation on this notice or, if you need more space,

attach a separate page to this notice.

3 Fill in all of the following:

Your or your representative’s full name (print)

Your telephone number

Your complete Medicare number

4 Include any other information you have about your appeal.

You can ask your facility for any information that will help you.

5 Write your Medicare number on all documents that you send.

6 Make copies of this notice and all supporting documents for

your records.

7 Mail this notice and all supporting documents to the

following address:

Medicare Claims Office

c/o {A/B MAC (A), (B), (HHH), or DME MAC Name}

{MAC Street Address}

{MAC City}, {ST} {ZIP+4}

PART B (ASSIGNED AND UNASSIGNED), HOSPICE, AND HOME

HEALTH

SPECIFICATIONS

CONTENT

File an Appeal in Writing

1 Circle the service(s) or claim(s) you disagree with on this

notice.

2 Explain in writing why you disagree with the decision.

Include your explanation on this notice or, if you need more space,

attach a separate page to this notice.

3 Fill in all of the following:

Your or your representative’s full name (print)

Your telephone number

Your complete Medicare number

4 Include any other information you have about your appeal.

You can ask your provider for any information that will help you.

5 Write your Medicare number on all documents that you send.

6 Make copies of this notice and all supporting documents for

your records.

7 Mail this notice and all supporting documents to the

following address:

Medicare Claims Office

c/o {A/B MAC (A), (B), (HHH), or DME MAC Name}

{MAC Street Address}

{MAC City}, {ST} {ZIP+4}

DME (ASSIGNED AND UNASSIGNED) SPECIFICATIONS

CONTENT

File an Appeal in Writing

1 Circle the item(s) or claim(s) you disagree with on this notice.

2 Explain in writing why you disagree with the decision.

Include your explanation

on this notice or, if you need more space, attach a separate page to

this notice.

3 Fill in all of the following:

Your or your representative’s full name (print)

Your telephone number

Your complete Medicare number

4 Include any other information you have about your appeal.

You can ask your supplier for any information that will help you.

5 Write your Medicare number on all documents that you send.

6 Make copies of this notice and all supporting documents for

your records.

7 Mail this notice and all supporting documents to the

following address:

Medicare Claims Office

c/o {A/B MAC (A), (B), (HHH), or DME MAC Name}

{MAC Street Address}

{MAC City}, {ST} {ZIP+4}