(Medicare Claims Processing Manual)

Delivery when change of care is due to physician orders   The HHA should review the text associated with the box that was checked on the HHCCN by the HHA, and inform the beneficiary that the HHA will no longer provide certain care because the physicians order has changed.  When requested, the HHA may facilitate contact and understanding between the physician and beneficiary. The beneficiary may also seek to contact the physician directly.  Retention of the HHCCN   The HHA keeps a copy of the completed, signed or annotated HHCCN in the beneficiarys record, and the beneficiary receives a copy. HHAs may retain a scanned copy of the paper copy document in an electronic medical record if desired.  The primary HHA must retain the HHCCN if a subcontractor is used.  Applicable retention periods are discussed in Chapter 1 of this manual, 110.  In general, this is 5 years from discharge when there are no other applicable requirements under State law.   Other Considerations During Completion   1.  Beneficiary Unable to Sign   If the beneficiary is physically unable to sign the HHCCN and is fully capable of understanding the notice a representative is not required for signature. The beneficiary may allow the HHA to annotate the HHCCN on his/her behalf regarding this circumstance. For example, a fully cognizant beneficiary with two broken hands may allow an HH A staff person to sign and date the notice in the presence of and under the direction of the beneficiary, inserting the beneficiarys name along with his/her own name, i.e., John Smith, Shiny HHA, signing for Jane Doe. Such signatures should be witnessed  by a second person whenever possible. Further, the medical record should support the beneficiarys inability to write in the applicable time period.   2.  Timely Notice   There are no exact time frames for HHCCN delivery.  Delivery timing of the notice may sometimes occur immediately upon the HHA finding that a change in care is warranted. However, in general, HHCCN should be delivered far enough in advance of the care chan ge so that the beneficiary may pursue alternatives to continue receiving the care noted on the HHCCN. When plans for issuance of the notice are known in advance, the HHCCN should not be issued so far in advance as to cause confusion regarding the information it conveys.  Some allowance is made for immediate delivery prior to furnishing the care at issue when unforeseen circumstances arise such as an impending, unforeseen agency staffing shortage or a dangerous home situation.  This should be avoided whenever possible, but is permissible when a situation occurs prompting an immediate determination to reduce or end services that could not have been made in advance.   70 - Skilled Nursing Facility Advance Beneficiary Notice of Non- (Rev.: 4198; Issued: 01-11-19; Effective: 04 -30-18; Implementation: 04- 30-18)   The following are the standards for use by Skilled Nursing Facilities (SNFs) in implementing the SNF ABN (CMS -Approved Model Form CMS -10055) requirements. This section provides instructions, consistent with the SNF prospective payment system (SNF PPS), reg arding the SNF ABN.   SNF ABN -  Quick Glance Guide3  3  This is an abbreviated reference tool and is not meant to replace or supersede any of the directives contained in Section 7 0.   Notice Name:  SNF ABN  Notice Number:  CMS -Approved Model, Form CMS -10055  Issued by:  SNFs for non- covered SNF PPS extended care items or  services.  Recipient:  Original Medicare fee- for-service (FFS) beneficiary   Additional Information:    The ABN, Form CMS -R-131 should be used for Part B non -covered items or services.  SNFs should no longer use the 5 SNF Notices of Non- coverage (Denial Letters) or the NEMB -SNF (CMS -20014) as these have been discontinued with the 2018 SNF ABN revision.   Type of Notice:  Must be issued in order to transfer liability to the beneficiary:  Timing of notice:  Optional/Voluntary use: Financial liability notice  Before SNF PPS extended care items or services are furnished, reduced, or terminated when the SNF, the UR entity, the QIO, or the Medicare contractor believes that Medicare may not pay for, or will not continue to pay for, those extended care services on the basis of one of the following statutory exclusions:    Not reasonable and necessary (medical necessity) for the diagnosis or treatment of illness, injury, or to improve the functioning of a malformed body member (1862(a)(1) of the Act); or   Custodial care (not a covered level of care) (1862(a)(9) of the Act).  Prior to delivery of the care item or service in question. Provide enough time for the beneficiary to make an informed decision on whether or not to receive the service or item in question and accept potential financial liability.   Yes.  It is recommended, but not necessary to transfer liability, for SNFs to issue prior to furnishing a care item or service that is never covered by Medicare (i.e. not a Medicare benefit).    70.1 - SNF ABN Standards  (Rev.: 4198; Issued: 01- 11-19; Effective: 04 -30-18; Implementation: 04 -30-18)  Step by step instructions for notice completion are posted along with the online replicable copies of the CMS -Approved Model, Form CMS -10055 on the CMS website. SNFs must not add any customizations to the notice beyond what is permitted by the accompanying SNF ABN form instructions and the guidelines published in this section. SNFs should follow the same standards when completing the SNF ABN as the ABN, Form CMS -R-131 in 50.6 of this chapter, as applicable.        70.2 - Situations in Which a SNF ABN Should Be Given  (Rev.: 4198; Issued: 01- 11-19; Effective: 04 -30-18; Implementation: 04 -30-18)   A.  Triggering Events   A SNF ABN is evidence of beneficiary knowledge about the likelihood of a Medicare denial, for the purpose of determining financial liability for expenses incurred for extended care items or services furnished to a beneficiary and for which Medicare does not pay.  If Medicare is expected to deny payment (entirely or in part) on the basis of one of the exclusions listed in 70 of this chapter for extended care items or services that the SNF furnishes to a beneficiary, a SNF ABN must be given to the beneficiary in order to transfer financial liability for the item or service to the beneficiary.  The initiation, reduction and termination of such extended care items or services, that Medicare may not pay, are considered triggering events. The following describe the three triggering events for a SNF ABN:   EVENT  DESCRIPTION  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 SNF ABN 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 beneficiarys 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 frequ ency of care that a physician has ordered, the SNF must provide a SNF ABN 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.   B.  Effect of Other Insurers/Payers    Some States have specific rules established regarding completion of liability notices in situations where dual -eligibles need to accept liability for Medicare non -covered care that will be covered by Medicaid.  Medicaid has the authority to make this asser tion under Title XIX of the Act, where Medicaid is recognized as the payer of last resort, meaning other Federal programs like Medicare (Title XVIII) must pay in accordance with their own policies before Medicaid picks up any remaining charges.  If the patient is a Medicare- Medicaid dual -eligible and a triggering event occurs, the SNF needs to give the beneficiary a SNF ABN.   On a practical basis, physician -prescribed items or services continue without interruption or reduction when a patient changes payer eligibility from Medicare to Medicaid.  From the Medicare coverage vantage- point, however, there is a reduction or termination when Medicare, which has been paying, stops paying.  In other words, there is a triggering event, which underlies the change in payer eligibility.  In these instances, a SNF ABN must be issued to transfer financial liability to the beneficiary.        70.3 - Situations in Which a SNF ABN Is Not Needed to Transfer Financial Liability to the Beneficiary  (Rev.: 4198; Issued: 01- 11-19; Effective: 04 -30-18; Implementation: 04 -30-18)   SNFs need not issue a SNF ABN to transfer financial liability to the beneficiary:    If the extended care item or service is not a Medicare benefit (e.g., personal comfort items excluded under 1862(a)(6)).    If a beneficiary is being furnished post -hospital extended care services while a resident in a SNF and payment is expected to be denied for an otherwise Medicare covered benefit because it does not meet a technical benefit requirement (e.g., SNF stay not preceded by the required prior three -day hospital stay or the beneficiary is exhausting his/her 100 benefit days).    If Medicare is expected to deny payment for Part B covered medical and other health services which the SNF furnishes, either directly or under arrangements with others, to an inpatient of the SNF, where payment for these services cannot be made under Part A ( e.g., the beneficiary has exhausted his/her allowed days of inpatient SNF coverage under Part A in his/her current spell of illness or was determined to be receiving a non -covered level of care).    If the SNF will not furnish the extended care items or services.  A SNF must not give a beneficiary a SNF ABN and then refuse to furnish extended care items or services even though the beneficiary elects to receive these items or services by selecting Opti on 1, as this is equivalent to the prohibited practice of the SNF pre -selecting Option 2 (not to receive items or services) on a SNF ABN.  This rule also applies when the beneficiary agrees with the triggering event (i.e., terminating therapy) and the bene ficiary will not be receiving the extended care items or services.   NOTE:   This rule is not applicable in the situation where the beneficiary elects to receive extended care items or services but refuses to sign the SNF ABN attesting to being personally and fully responsible for payment, in which case, the SNF may then consider  not furnishing the specified items or services.   For Medicare Advantage (Part C) enrollees nor for non- Medicare patients because it is to be used solely for individuals enrolled in the Medicare FFS program (Parts A and B).    When extended care items or services are reduced or terminated in accordance with a physicians order, where a physician does not order the items or services at issue, or where the physician agrees in writing with the SNFs, the UR entitys, the QIOs, or the Medicare contractors assessment that the extended care items or services are not necessary.    For swing- bed determinations.  The Preadmission/Admission HINN (HINN 1) should be given.   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.