(Medicare Claims Processing Manual)

Background of the Subject   The subjects business name, address, Medicare Identification Number, owners full name and Social Security Number, Tax Identification Number (if different), and a brief description of the subjects special field of medical equipment, supplies, or services.   Origin of the  Case   A brief description of how the violations were discovered.   Statement of Facts   A statement of facts in chronological order describing each failure to comply with the refund requirements.   Written Correspondence and Written Summaries  Copies of any meetings or telephone contacts with the beneficiary and the supplier regarding the suppliers failure to make a refund.  List of the following for each item or service not refunded to the beneficiary by the supplier (grouped by beneficiary):   Beneficiary Name and Medicare beneficiary identifier;  Claim Control Number;  Procedure Code (CPT -4 or HCPCS) of non-refunded item or service;  Procedure Code modifier;  Date of Service;  Place of Service Code;  Submitted Charge;  Units (quantity) of Item or Service; and  Amount Requested to be refunded.  Additional Information  Any information that may be of value to the RO.   50.17  ABN Special Considerations  (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21)  A.  Obligation to Bill  Medicare   Upon receipt of an ABN, beneficiaries always have the right to ask the notifer to submit a claim to Medicare for an official payment decision.  A beneficiary must receive the item/service described in the ABN and choose Option 1 in order to request Medicar e claim submission.   Healthcare providers or suppliers should refer to Publication 100- 4, Chapter 1, Section 60 for instructions on submitting claims for statutorily non- covered items or services.   Note : Healthcare providers or suppliers will not violate mandatory claims submission rules under Section 1848 of the Social Security Act when a claim is not submitted to Medicare at the beneficiarys request by their choice of Option 2 on the ABN.  B.  Dually Eligible Individuals (Has a Qualified Medicare Beneficiary (QMB) Program and/or  Medicaid coverage)   Dually Eligible beneficiaries must be instructed to check Option Box 1 on the ABN in order for a claim to be submitted for Medicare adjudication.  The provider must strike through Option Box 1 as provided below:    OPTION 1. I want the  (D)  listed above.  You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesnt pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN.   These edits are required because the provider cannot bill the dual eligible beneficiary when the ABN is furnished. Providers must refrain from billing the beneficiary pending adjudication by both Medicare and Medicaid in light of federal law affecting cove rage and billing of dual eligible beneficiaries. If Medicare denies a claim where an ABN was needed in order to transfer financial liability to the beneficiary, the claim may be crossed over to Medicaid or submitted by the provider for adjudication based on State Medicaid coverage and payment policy. Medicaid will issue a Remittance Advice based on this determination.   Once the claim is adjudicated by both Medicare and Medicaid, providers may only charge the patient in the following circumstances:    If the beneficiary has QMB coverage without full Medicaid coverage, the ABN could allow the provider to shift financial liability to the beneficiary per Medicare policy.    If the beneficiary has full Medicaid coverage and Medicaid denies the claim (or will not pay because the provider does not participate in Medicaid), the ABN could allow the provider to shift financial liability to the beneficiary per Medicare policy, subject to any state laws that limit beneficiary  liability.  Note: These instructions should only be used when the ABN is used to transfer potential financial liability to the beneficiary and not in voluntary instances. More information on dual eligible beneficiaries may be found at: https://www.cms.gov/Outreach -and-Education/Medicare- Learning- Network - MLN/MLNProducts/downloads/Medicare_Beneficiaries_Dual_Eligibles_At_a_Glan ce.pdf   C.  Ambulance  Transports   Emergency or urgent situations  In general, a notifier may not issue an ABN to a beneficiary who has a medical emergency or is under similar duress.  Forcing delivery of an ABN during an emergency may be considered coercive.  ABN usage in the ER may be appropriate in some cases where the beneficiary is medically stable with no emergent health issues.  Non -emergent/urgent ambulance transport  If the provider or supplier wants to transfer liability to the beneficiary, issuance of the ABN is mandatory for ambulance transport services if all of the following 3 criteria are met::   1. The service being provided is a Medicare covered ambulance benefit  under 1861(s)(7) of the SSA and regulations under this section as stipulated in 42 CFR  410.40 -.41;  2. The healthcare provider or supplier believes that the service may be denied, in part or in full, as not reasonable and necessary under  1862(a)(1)(A) for the beneficiary on that particular occasion;  and  3. The ambulance service is being provided in a non -emergency situation.  (The patient is not under  duress.)   ABN issuance is mandatory only when a beneficiarys covered ambulance transport is modified to a level that is not medically reasonable and necessary and will incur additional costs.  If an ambulance transport is statutorily excluded from coverage because it fails to meet Medicares definition of the ambulance benefit, a voluntary ABN may be issued to notify the beneficiary of his/her financial liability as a courtesy.   D. Hospice   Mandatory use of the ABN is very limited for hospices.  Hospice providers are responsible for providing the ABN when required as listed below for items and services billable to hospice.  Hospices are not responsible for issuing an ABN when a hospice patien t seeks care outside of the hospices jurisdiction.  The three situations that would require issuance of the ABN by a hospice are:    Ineligibility because the beneficiary is not determined to be terminally ill as defined in 1879(g)(2) of the  Act; or   Specific items or services that are billed separately from the hospice payment, such as physician services, are not reasonable and necessary as defined in  either 1862(a)(1)(A) or 1862(a)(1)(C); or    The level of hospice care is determined to be not reasonable or medically necessary as defined in 1862(a)(1)(A) or 1862(a)(1)(C), specifically for the management of the terminal illness and/or related  conditions.  Note:   It is the hospices responsibility to issue an ABN when a beneficiary who has elected the hospice benefit chooses to receive inpatient hospice care in a hospital that is not under contract with the hospice.  The hospice may delegate delivery of the ABN t o the hospital in these cases.   End of all Medicare covered hospice care    When it is determined that a beneficiary who has been receiving hospice care is no longer terminally ill and the beneficiary is going to be discharged from hospice, the hospice may be required to issue the Notice of Medicare Non- coverage (NOMNC), CMS 10123.  If upon discharge the patient wants to continue rec eiving hospice care that will not be covered by Medicare, the hospice would issue an ABN to the beneficiary in order to transfer liability for the non -covered care to the beneficiary.  If no further hospice services are provided after discharge, ABN issuan ce would not be required.  ABNs are not required for Hospice Services in these situations:    Revocations -  Hospice beneficiaries or their representatives can revoke the hospice benefit.  Revocations are not considered terminations under liability notice policy since the beneficiary is exercising his/her own freedom of choice.  Therefore, no ABN is required.    Respite Care Beyond Five Consecutive Days -  Respite care is limited to five consecutive days under the Act.  When respite care exceeds five consecutive days, an ABN is not required since additional days of respite care are not part of the hospice benefit.  CMS encourages hospice providers to give the ABN as an optional notice to inform patients of financial liability when more than five days of respite care will be provided.   Transfers -  Beneficiaries are allowed one transfer to another hospice during a benefit period.  However, subsequent transfers within the same benefit period are not permitted.  In either case, an ABN is not required.    Failure to Meet the Face to Face Requirement -  The ABN must not be issued when the face to face requirement for hospice recertification is not met within the required timeframe.  Failure to meet the face to face requirement for recertification should not be misrepresented as a determination that the beneficiary is no longer terminally ill.    Room and Board Costs for Nursing Facility Residents -  Since room and board are not part of the hospice benefit, an ABN would not be required when the patient elects hospice and continues to pay out of pocket for long term care room and board.   E.  Comprehensive Outpatient Rehabilitation Facility (CORF)   Since Comprehensive Outpatient Rehabilitation Facility (CORF) services are billed under Part B, CORF providers must issue the ABN according to the instructions given in this section.  The ABN is issued by CORFs before providing a service that is usually covered by Medicare but may not be paid for in a specific case because it is not medically reasonable and necessary.   When all Medicare covered CORF services are going to end, CORFs are required to issue a  notice regarding the beneficiarys right to an expedited determination called a NOMNC, CMS 10123.  Upon termination of all CORF care, the ABN would be issued only if the beneficiary wants to continue receiving some or all services that will not be covered by Medicare because they are no longer considered medically reasonable and necessary.  An ABN would not be issued if no further CORF services are provi ded.  F. Home Health Agency (HHA)   The following chart summarizes the statutory provisions related to ABN issuance for LOL purposes:   Application of LOL for the Home Health Benefit  Citation from the Act Brief Description of  Recommended Explanation          1862(a)(1)(A) Care is not reasonable and necessary  Medicare does not pay for care that is not medically reasonable and  1862(a)(9)  Custodial care is the only care delivered  Medicare does not usually pay for custodial care,      1879(g)(1)(A) Beneficiary is not homebound Medicare requires that a beneficiary cannot leave home (with certain exceptions) in order to cover services      1879(g)(1)(B) Beneficiary does not need skilled nursing care on an intermittent basis  Medicare requires part-time or intermittent need for skilled nursing care in order to cover        Triggering Events for ABN issuance by HHAs*   HHAs may be required to provide an ABN to an Original Medicare beneficiary when a triggering event occurs.   EVENT  DESCRIPTION  EXAMPLE  Initiation  An ABN must be issued to the beneficiary prior to receiving care that is usually covered by A beneficiary requires skilled nursing Medicare, but in this particular instance, it is not covered or may not be covered by Medicare because the care is not medically reasonable and  necessary, the beneficiary is not confined to his/her home (considered  homebound), or the beneficiary does not need skilled nursing care on an intermittent basis,  or the beneficiary is receiving custodial care  only.  wound care 3 times weekly; however, she is not confined to the home.  She wants the care done at her home by the HHA.