CMS Pub. 100-04, ch. 21, § 10.3.9

From time to time, beneficiaries may receive an MSN that includes a check, refunding an

overpayment made (most often) for Part B services, either assigned or unassigned. The

instructions below describe the cover sheet and check page. This page is inserted before

the notice itself.

The MACs are not required to change their process of producing checks, but encouraged

to revise fonts and formatting to reflect the redesign. The check must have the DHHS

seal, not the CMS logo as previously used.

A. Recipient Address

POSITION

This subsection contains information of a variable size. The following specification is

the same as Section 10.3.3.C, Recipient Address subsection.

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. See figure 10.3.3.C for layout reference.

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 10.3.8.A.

FORMATTING

[TB 1.1] all text, all caps

DYNAMIC RULES

All of the content in this subsection is dynamically generated. It should be identical to the

recipient address printed on page 1 of the MSN. Please see Section 10.3.3, part C, for

detailed dynamic rules for the recipient address.

CONTENT

The recipient address printed here should be identical to the recipient address printed on

page 1 of the MSN. Please see Section 10.3.3, part C, for detailed information on the

content of the recipient address.

B. Check Notification

This subsection contains a high-priority message to beneficiaries indicating that a check

is enclosed.

POSITION

This subsection contains static text content.

The content area begins (0˝, 4˝), is one-column or 259 points in width with 64 points in

height.

FORMATTING

[TH 4] Big Header, all caps, center aligned

DYNAMIC RULES

N/A - this section is static.

CONTENT

MEDICARE PART B CHECK

DO NOT DESTROY

PLEASE CASH AS SOON AS POSSIBLE

C. Check

This subsection contains the check refunding funds to the beneficiary. The positioning,

formatting, and content of this dynamic content is variable, depending on the check-printing practices of each MAC. The one consistent element is the DHHS seal, described

below.

POSITION

Align to the top of the top of the check content area. Content should be centered

horizontally.

The content area is 193 points in width with 53 points in height.

See Exhibit 2.13 for layout reference.

FORMATTING

[GL 3] Check logo

DYNAMIC RULES

As noted above, the dynamic content on the check is variable, depending on the check-printing practices of each MAC.

CONTENT

As noted above, the dynamic content on the check is variable, depending on the check-printing practices of each MAC.

D. Notice Title on Check Page

Depending on the check-printing practices of the MAC, the Notice Title subsection on

the MSN may be repeated on the check page. Glyph files, GL 4 (Part A), GL5 (Part B)

and GL6 (Part A and B combined), are available as flash images of the 3 different types

of Titles. See Section 10.3.3.A for detailed specifications.