17. When your Benefit Period Starts
This shows when your current benefit period began.
18. Benefit Days Used
This is the number of benefit days you used during your hospital stay.
19. Service Approved?
“Yes” means that Medicare covers this type of health care service. If you see “No” in this space, contact the facility and ask for an itemized statement. Also see the section How to Handle a Denied Claim at item No. 26. To challenge an unpaid charge, see “Appealing a Medicare Claim Decision.”
20. Non-Covered Charges
For more about hospital charges Medicare does not cover, see "What Medicare Doesn't Cover."
21. Amount Medicare Paid
This is the amount Medicare paid the facility for this claim.
22. Maximum You May Be Billed
This is the maximum amount the facility can bill you. It may include your deductible ($1,216 in 2014 for each benefit period), your coinsurance charges for stays over 60 days in your benefit period or other charges that Medicare does not cover. Compare your Medicare Summary Notice with the facility’s billing statement to make sure you are paying the correct amount. Contact the facility if you spot errors in this section of your MSN.
23. See Notes Below
This column directs you to additional information about your claims. If there’s a letter in this column, refer to the Notes for Claim Above (described by item No. 25) at the bottom of the page for explanations of the claims on this Medicare Summary Notice.
24. Claim Number
Each claim made to your Medicare Part A account is assigned a distinct number. Refer to this claim number when speaking with the facility or Medicare.
25. Notes for Claim Above
Medicare uses this area to give you extra information about the claims listed in your Medicare Summary Notice. For instance, the message shown here is about benefit days and coinsurance.
26. How to Handle a Denied Claim or File an Appeal
Follow the steps in this section if Medicare denies payment for a claim you think should have been paid. Your appeal must be in writing. Print a copy of your online MSN at MyMedicare.gov, which includes this appeal page, or use the form you get in the mail with your paper MSN.
Complete the form by hand. Be sure to make a copy of everything you send to Medicare, and send it by recorded delivery or keep a note of when you mailed it.
For more information about appealing a denial and deadlines for filing, see Appealing a Medicare Claim Decision.
27. If You Disagree with a Coverage Decision, Payment
You have 120 days to appeal your claim. The date listed in the box is when your appeal must be received at the Medicare Claims Office. The address you should use is at the bottom of the form.