United States

Senior Living Health Care Connection: Beneficiary notices clarified

SENIOR LIVING HEALTH CARE CONNECTION  | 

Centers for Medicare and Medicaid Services (CMS) mandated the use of a new skilled nursing facility advance beneficiary notice (SNF ABN) as of May 7, 2018. There has been confusion regarding some aspects of the beneficiary notices required by CMS. Here is a summary of notices that are required:

Notice 

 

When used

Generic notice – Notice of Medicare noncoverage (NOMNC) (CMS-10123)

 

Notifies a resident or responsible party that skilled service is ending and the option to appeal to the quality improvement organizations is available (QIO)

 

Detailed notice – Detailed explanation of noncoverage (DENC) (CMS-10124)

 

Completed when an appeal to the Quality Improvement Organizations (QIO) program is made

 

SNF ABN (CMS-10055)

 

Notifies a resident on a continued stay that they may be financially liable after skilled service ends

 

Medicare Part B denials – ABN of noncoverage (Form CMS-R-131)

 

Given when the provider believes that the therapy services may not be covered, because the services may not be reasonable and necessary and the beneficiary will be responsible for the charges

 

The requirements for completing the NOMNC and the DENC have not changed. These notices are also used for Medicare Advantage beneficiaries. CMS clarified that the SNF ABN should not be used for managed care beneficiaries (Medicare Advantage). Per CMS, “Medicare health plans and providers are to follow the regulatory requirements related to the right of the enrollee to request an organization determination and to receive an appropriate notice in accordance with 42 CFR §§ 422.568 and 422.572.”

Medicare health plans are required to issue the integrated denial notice (IDN) upon denial, in whole or in part, of an enrollee's request for coverage and upon discontinuation or reduction of a previously authorized course of treatment. The revised IDN, Form CMS-10003—notice of denial of medical coverage (or payment), and form instructions—has been approved by the Office of Management and Budget. Plans should take note of the expiration date in the revised form and instructions.

Questions? Contact Joan McCarthy at +1 312 634 3479.

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