Medicare beneficiaries in a SNF have rights and safeguards with regard to financial liability and appeal of the denial of Medicare services. Providers are required to inform beneficiaries of their financial liability and their appeal rights in writing by issuing specific notices. Is your facility consistently meeting the requirements of F582 related to Medicaid and Medicare coverage and the issuance of liability notices?
There are two separate and distinct notices that may be required to be issued depending on the specific circumstances surrounding each beneficiaries stay:
- Notice of Medicare Non-Coverage (NOMNC) (CMS-10123): This notice informs the beneficiary of their ability) to request an appeal when seeking to overturn the facility’s clinical decision to end coverage.
- Notice of Medicare Denial of Coverage (SNF ABN ): This notice informs beneficiaries of their financial liability for expenses after coverage ends and advises that they can request a demand bill.
Failure to comply with the regulations and to properly issue the notices to each beneficiary when required can have both survey/regulatory compliance and financial/provider liability implications for SNF providers. Ensuring that effective processes are in place to issue notices that are timely and complete is essential to compliance. It is critical to know which forms to issue, to whom, and when, in accordance with current Federal requirements. §483.10 Resident Rights – F582 Medicaid/Medicare Coverage / Liability Notice
Notice of Medicare Non-Coverage (NOMNC)
When a Medicare provider or health plan determines that a patient’s care needs no longer meet skilled coverage criteria, the provider is obligated to notify the patient in writing of this coverage decision. The Notice of Medicare Non-coverage (NOMNC) CMS FORM 10123 is the required form for issuing this notice. The notice is required to be issued to both Medicare Part A FFS Beneficiaries AND participants in Medicare Advantage plans. This notice is required to be issued to Medicare beneficiaries at least two days prior to the last covered Medicare day. The NOMNC informs the beneficiary of the right to an expedited review by a Quality Improvement Organization. See also 42 CFR 405.1200 and 422.624.
The NOMNC is not given if:
- The beneficiary exhausts the SNF benefits coverage (100 days), thus exhausting their Medicare Part A SNF benefit.
- The beneficiary initiates the discharge from the SNF.
- The beneficiary elects the hospice benefit or decides to revoke the hospice benefit and return to standard Medicare coverage.
In situations where the NOMNC is not given, such as a discharge that is initiated by the beneficiary, the medical record documentation should clearly support the reason for not issuing the notice.
Prior to, and throughout a beneficiary’s Part A SNF stay, the level of care determination should be reviewed for ongoing appropriateness. The SNF provider must issue the SNFABN to beneficiaries of traditional Medicare Part A when the determination is made that the beneficiary does not meet the skilled need criteria for nursing and/or rehabilitation services provided on a daily basis in order for Medicare to pay for the beneficiary’s SNF stay. When a Medicare recipient does not qualify for a skilled level of care, the SNF ABN, CMS-10055, is given when (1) the beneficiary has Medicare days available in the benefit period and (2) continued to reside in the SNF receiving non covered care. The notice informs the beneficiary of their financial liability for the cost of non-covered services and their right to request an appeal of this determination through the demand bill process. Per Chapter 30, section 70.2 of the Medicare Claims Processing Manual (IOM Pub. 100-04), a SNFABN must be given to a beneficiary for the following triggering events:
- Initiation – In the situation in which a SNF believes Medicare will not pay for extended care items or services that a physician has ordered, the SNF must provide a SNFABN to the beneficiary before it furnishes those non-covered extended care items or services to the beneficiary.
- Reduction – In the situation in which a SNF proposes to reduce a beneficiary’s extended care items or services because it expects that Medicare will not pay for a subset of extended care items or services, or for any items or services at the current level and/or frequency of care that a physician has ordered, the SNF must provide a SNFABN to the beneficiary before it reduces items or services to the beneficiary.
- Termination – In the situation in which a SNF proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF must provide a SNF ABN to the beneficiary before it terminates such extended care items or services.
During survey, the survey team will validate compliance with the regulations related to beneficiary notices utilizing the SNF Beneficiary Protection Notification Review Process. To complete this review process, surveyors will request the facility provide a list of Medicare Part A beneficiaries who were discharged from Medicare covered services with benefit days remaining during the past 6 months. From this list, the surveyor will randomly select three beneficiaries, with a focus on residents who remained in the facility, to review compliance with the notices. If the determination is made that the above notices were not properly issued in compliance with the requirements, the surveyor will site F582 (Medicaid/Medicare Coverage/Liability Notices) and may also site F550 (resident rights).
It is important for SNF providers to have a strong understanding of the notice requirements, have sound systems and processes in place for each type of notice issued and follow the form instructions to ensure compliance. Compliance can be validated through periodic auditing and monitoring activities as part of ongoing survey preparedness and quality assurance processes.
Join Proactive on March 14, 2023 the next webinar in our Deep Dive Into Federal Regulations in a Year series as we examine in depth the regulations related to §483.15 Admission Transfer & Discharge Rights
Additional References: Beneficiary notices initiative (BNI). CMS. (n.d.). https://www.cms.gov/Medicare/Medicare-General-Information/BNI
Written By: Jessica Cairns, RN, RAC-CT, CMAC
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