(Medicare Claims Processing Manual)

NOTE:   An ABN, Form CMS -R-131 may be required if a SNF has been acting as a supplier of Part B services or supplies outside a physicians plan of care.  See Section 50 of this manual, as applicable.    70.4 - SNF ABN Specific Delivery Issues  (Rev.: 4198; Issued: 01- 11-19; Effective: 04 -30-18; Implementation: 04 -30-18)    When completing and delivering the SNF ABN, SNFs must meet the written notice standards in 50.6 and 50.7 of this chapter, unless otherwise specified.  Failure to provide a proper SNF ABN in situations where a physician has ordered the extended care item or service may result  in the SNF being held financially liable under the LOL provisions, where such provisions apply.  SNFs may also be sanctioned for violating the conditions of participation ( 42 CFR 483.10) regarding resident (beneficiary) rights.   NOTE:  The SNF ABN is not a replacement for, but is in addition to, the required UR entity notices .  The SNF ABN protects the SNF from liability in the event the beneficiary, for some reason, does not receive the UR entity notice.                      70.5 - Special Rules for SNF ABNs  (Rev.: 4198; Issued: 01- 11-19; Effective: 04 -30-18; Implementation: 04 -30-18)   A.  Collection from Beneficiary   When a SNF ABN is properly executed and given timely to a beneficiary and Medicare denies payment on the related claim, the SNF must wait for the beneficiary to receive a Medicare Summary Notice (MSN) before it can collect payment on the related claim.  Medicare does not limit the a mount that the SNF may collect from the beneficiary in such a situation.  A beneficiarys agreement to be personally and fully responsible for payment means that the beneficiary agrees to pay out of pocket or through any other insurance that the benefici ary may have, e.g., through employer group health plan coverage, through Medicaid, or through some other Federal or non- Federal payment source.   NOTE:   The beneficiary may request a demand bill at any point in her or his care.   B.  Unbundling Prohibition  The SNF ABNs may not be used to shift financial liability to a beneficiary in the case of services for which full payment is bundled into other payments; that is, where the beneficiary would otherwise not be financially liable for payment for an extended c are item or service because Medicare made a bundled payment.  Using a SNF ABN to collect from a beneficiary where full payment is made on a bundled basis would constitute double billing.  A SNF ABN may be used to shift financial liability to a beneficiary in the case of extended care items or services for which partial payment is bundled into other payments; that is, where part of the cost is not included in the bundled payment made by Medicare.   C.  Acceptance or Rejection of SNF ABN   These instructions are to assist the Medicare contractor in advising SNFs with respect to their responsibilities in advising beneficiaries with respect to their rights and protections and in dealing with complaints from beneficiaries, or authorized represe ntatives, about the lack of notice or defective notice.  The SNF should:    Answer inquiries from a beneficiary regarding the basis for the SNFs, the UR entitys, the QIOs, or the Medicare contractors assessment that extended care items or services may not be covered and, if requested by the beneficiary, the SNF must give the beneficiary access to medical record information or other documents upon which these entities  based their assessment, to the extent permissible or required under applicable state law.   NOTE:   Where state law prohibits such direct disclosure, the SNF should advise a beneficiary who has requested access to such information how to obtain that information from the SNF once a demand bill has been submitted.    Respond timely, accurately, and completely to a beneficiary who requests information about the extent of the beneficiarys personal financial liability.    Timely submit additional information to the Medicare contractor, if a beneficiary or a physician provides that additional information with respect to Medicare coverage of the subject extended care items or services.   70.6 - Establishing When Beneficiary Is On Notice of Non -coverage  (Rev.: 4198; Issued: 01- 11-19; Effective: 04 -30-18; Implementation: 04 -30-18)   If the beneficiary has previously been informed in writing that similar or reasonably comparable extended care items or services were non -covered and it was clear that the beneficiary knew that the circumstances were the same, the beneficiary is liable.  With this exception, the beneficiary is presumed not to have known, nor to have been expected to know, that the extended care items or services are not covered unless, or until, s/he receives notification from an appropriate source.   70.6.1 - Source of Beneficiary Notification   (Rev.: 4198; Issued: 01- 11-19; Effective: 04 -30-18; Implementation: 04 -30-18)   Written Notification must be given by one of the following sources:   A.  The SNF that is furnishing non- covered extended care items or services.   Examples:    On or before the day of admission, the SNF furnishes to the beneficiary a SNF ABN notifying the beneficiary that the extended care item(s) or service(s) is non-covered; or    During the inpatient stay, the SNF timely furnishes to the beneficiary a SNF ABN notifying the beneficiary that the covered extended care item(s) or service(s) will no longer be covered.   B.  The UR entity of the SNF that is furnishing non- covered extended care items or services.   Example:    The UR entity timely furnishes to the beneficiary a SNF ABN notifying the beneficiary that the extended care item(s) or service(s) is no longer covered.   C.  The QIO or Medicare contractor.   Example:    The QIO, where a beneficiary is in a swing bed, timely furnishes to the beneficiary, a SNF ABN notifying the beneficiary that the extended care item(s) or service(s) is not covered or the item(s) or service(s) is no longer covered.  NOTE:   This occurs after the beneficiary receives a HINN 1 (Preadmission/Admission HINN) and after the QIOs decision of the non -coverage.    The Medicare contractor sends the beneficiary her or his first notification of non-coverage (e.g., the MSN).      70.7  70.13 New sections to be added     80 - Hospital ABNs (Hospital-Issued Notices of Noncoverage - HINN)  (Rev. 594, Issued: 06- 24-05, Effective: 07 -01-05, Implementation: 07- 01-05)  Instructions for the Hospital ABN have been retracted. Instructions related to HINNs have been relocated as follows:    Instructions regarding HINNs are found in this instruction, CR 3903, which precedes the placement of full instructions in Chapter 30.   Instructions regarding hospital billing for cases involving QIO review will be relocated to a new section in Chapter 1 of this manual in the near future. Current procedures should not change in the interim.   Related instructions for QIOs can be found in the Medicare Quality Improvement Organization Manual, Publication 100- 10, Chapter 7.  100 - Indemnification Procedures for Claims Falling Within the Limitation on Liability Provision  (Rev. 1, 10- 01-03)  Section 1879(b) of the Act provides that when a provider, practitioner, or supplier is held liable for the payment of expenses incurred by a beneficiary for noncovered items or services and such provider, practitioner, or supplier requests and receives payment from the beneficiary or any person(s) who assumed financial responsibility for payment of expenses, the Medicare program indemnifies the beneficiary or other person(s).   Further, any such indemnification payments are considered overpayments to the provider, practitioner, or supplier.   A provider, practitioner, or supplier who is determined liable may not seek payment from a third party payer. (See 30.2.B .)  100.1 - Contractor and Social Security Office (SSO) Responsibility in Indemnification Claims  (Rev. 1, 10- 01-03)  The contractor, SSO, RO, or central office may receive requests or inquiries concerning indemnification. However, a beneficiary or person(s) who made payment on behalf of the beneficiary to a liable provider usually visits his/her nearest SSO or deals dire ctly with the contractor to file a request for indemnification.   Those offices are responsible for assisting beneficiaries or any person(s) in filing claims for indemnification.   100.2 - Conditions for Indemnification  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  A beneficiary or any person(s) who assumed financial responsibility for payment is indemnified for claims filed if all of the following conditions are met:    The contractor has determined that the beneficiary is without liability under authority of 1879 of the Act for items and services furnished by a provider, practitioner, or supplier;    The contractor or the QIO has determined that the provider, practitioner, or supplier is liable under 1879 for the items and services furnished to the beneficiary. A provider, practitioner, or supplier is considered to have knowledge that payment will n ot be made under Medicare for items or services in a particular claim where the following evidence is established regarding the provider, practitioner, or supplier;   (1) Evidence that a provider, practitioner, or supplier knew, or could reasonably be expected to have known, of exclusion of items or services   o General notice to the medical community regarding exclusion of certain items or services: e.g., colonic irrigation, acupuncture.   o General notice to the medical community that services exceeding certain frequencies would be denied or subject to additional review, e.g., vitamin B12 injections, or nursing home visits more frequent than once a month.  o Written notice to the particular provider, practitioner, or supplier that a type of service or item would be noncovered in all or certain circumstances.   A distinction must be maintained between coverage rules that specify that a type of service or item would be not reasonable or necessary in all or certain circumstances, and utilization guidelines the contractor established to identify excessive services. Any written policies or other internal edits that are disclosed to a provider, practitioner, or supplier would not be considered as a notice of exclusion, since they are used for referring claims for further development rather than as rules to make a con tractor coverage decision.   In addition to instances when the Medicare program has given notice, the allegation of a provider, practitioner, or supplier is not accepted without further verification in situations of potential program abuse involving a pattern of unnecessary services b y a provider, practitioner, or supplier to a number of beneficiaries. When a provider, practitioner, or supplier frequently renders unnecessary services, i.e., services that significantly exceed the frequency with which the general medical community render s them, it is reasonable to expect the provider, practitioner, or supplier to know that such a pattern deviates from the standard practice.   (2) Evidence that provider, practitioner, or supplier did not have knowledge of exclusion of services.   In contrast to subsection 1, there may be situations where an assumption can be made that neither the beneficiary nor the provider, practitioner, or supplier had knowledge of exclusion, and liability can be limited by the reviewer without a statement by either party. In the following situations, further development would not be necessary:   a. The service is for a type of treatment that can be rendered only by a physician, but the contractor has not previously denied payment for the treatment, and it is not unreasonable that a particular physician might consider the treatment appropriate. In order to determine whether the services are reasonable and necessary, the contractor requests its physician consultant or CMS to advise whether the services are covered. This is a case for which there are no general coverage guidelines for the services; the contractor has not advised either the physician or the medical community regarding the coverage of the servic es; and the contractor is uncertain without expert consultation. In such a case, it may be presumed that neither the beneficiary nor the physician could have known that the services would be noncovered.   b. The item or service is ordinarily covered, but a question is raised as to whether it is reasonable and necessary in treatment of a particular diagnosis. Neither the provider, practitioner, or supplier nor the medical community has been advised that the item or service is not covered for that diagnosis. The case requires a determination by the contractors medical consultant or is referred to CMS for guidance. As in example (a), the liability of both parties should be limited.   c. The provider, practitioner, or supplier is newly arrived in the contractor service area, and the contractor has not yet communicated to the provider, practitioner, or supplier information in an existing general notice that the item or service is not cov ered, always or under certain circumstances.