evekhm/cms_iom_500 huggingface dataset:
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Skilled Nursing Facilities (SNFs) issue the ABN for Part B services only.  The Skilled Nursing Facility Advance Beneficiary Notice of Non- coverage (SNF ABN), CMS Form 10055, is issued for Part A SNF items and services.  Section 70 of this chapter contains information on SNFABN issuance.   50.2 - ABN  Uses                                                                                          (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21)  The following provisions necessitate delivery of the ABN:    1862(a)(1) of the Act (not reasonable and necessary);    1834(a)(17)(B) of the Act (violation of the prohibition on unsolicited telephone  contacts);    1834(j)(1) of the Act (medical equipment and supplies supplier number requirements not  met);    1834(a)(15) of the Act (medical equipment and/or supplies denied in advance);    1862(a)(9) of the Act (custodial  care);    1879(g)(2) of the Act (hospice patient who is not terminally ill);    1879(g)(1) of the Act (home health services requirements are not met  not confined to the home or no need for intermittent skilled nursing care);    1862(a)(1)(P) of the Act, Medicare covered personalized prevention plan services (as defined in 1861(hhh)(1) ) that are performed more frequently than indicated per coverage guidelines are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member);    Under 42 CFR 414.408(e)(3)(ii) when a noncontract supplier furnishes an item included in the Durable Medical Equipment, Prosthetic, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) for a Competitive Bidding Area (CBA).  Although all othe r denial reasons triggering mandatory use of the ABN are found in 1879 of the Act, in this situation, 1847(b)(5)(D) of the Act permits use of the ABN with respect to these items and services; or
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 When Medicare considers an item or service experimental (e.g., a Research Use Only or Investigational Use Only laboratory test), payment for the experimental item or service is denied under 1862(a)(1) of the Act as not reasonable and necessary.  In ci rcumstances such as this, the beneficiary must be given an ABN.  50.2.1 - Optional ABN Uses                                                                       (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21)  ABNs are not required for care that is either statutorily excluded from coverage under Medicare (i.e. care that is never covered) or most care that fails to meet a technical benefit requirement (i.e. lacks required certification).  However, CMS strongly encourage healthcare provide rs and suppliers to issue the ABN for care that is never covered such as:   Care that fails to meet the definition of a Medicare benefit as defined in 1861 of the Social Security  Act;   Care that is explicitly excluded from coverage under 1862 of the Social Security Act.  Examples  include:    Services for which there is no legal obligation to pay;  Services paid for by a government entity other than Medicare (this exclusion does not include services paid for by Medicaid on behalf of  dual-eligibles);  Services required as a result of war;   Personal comfort items;  Routine eye care;   Dental care; and   Routine foot  care.   When the ABN is used in this way it serves as a courtesy to the beneficiary in forewarning him/her of impending financial obligation.  The beneficiary should not be asked to choose an option box or sign the notice.  The healthcare provider or supplier is not required to adhere to the issuance guidelines for the ABN.   NOTE: Certain DME items/services that fail to meet a technical requirement may require an ABN as outlined in the mandatory use section above.   50.3 - Issuance of the ABN                                                                        (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21) Notifiers  May direct an employee or a subcontractor to deliver an ABN.  The billing entity will always be held responsible for effective delivery regardless of who gives the notice.
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When multiple entities are involved in rendering care, it is not necessary to give separate ABNs.  Either party involved in the delivery of care can be the notifier when:    There are separate ordering and rendering healthcare providers or supplier (e.g. a physician orders a lab test and an independent laboratory delivers the ordered tests);   One healthcare provider or supplier delivers the technical and the other the professional component of the same service ( e.g. a radiological test that an independent diagnostic testing facility renders and a physician interprets);  or  The entity that obtains the signature on the ABN is different from the entity that bills for services (e.g. when one laboratory refers a specimen to another laboratory which then bills Medicare for the  test).   When the notifier is not the billing entity, the notifier must know how to direct the beneficiary who received the ABN to the billing entity for questions and should annotate the Additional Information section of the ABN with this information.  It is permissible to enter the names of more than one entity in the header of the notice.  Representatives of Beneficiaries  If the beneficiary has a known, legally authorized representative, the ABN must be issued to the existing representative.  If a beneficiary does not have a representative and one is necessary, a representative may be appointed for purposes of receiving not ice following CMS guidelines and as permitted by State and Local law.  When a representative is signing the ABN on behalf of a beneficiary, the ABN should be annotated to identify that the signature was penned by the rep or representative.  If the representatives signature is not clearly legible, the representatives name should be printed on the ABN.  See section 500 of this manual under Authorized representative for more information.   50.4 - ABN Triggering Events                                                                   (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21)  Initiations   Reductions   Terminations   The beginning of a new patient encounter, start of a plan of care, or beginning of treatment.
(Medicare Claims Processing Manual)
Initiations   Reductions   Terminations   The beginning of a new patient encounter, start of a plan of care, or beginning of treatment.     A reduction occurs when there is a decrease in a component of care (i.e. frequency, duration, etc.).  The ABN is not issued every time an item or service is reduced.  But, if a reduction occurs and the beneficiary wants to receive care that is no longer considered medically reasonable and necessary, the ABN must be issued A termination is the discontinuation of certain items or services.  The ABN is only issued at termination if the beneficiary wants to continue receiving care that is no longer medically reasonable and necessary.    prior to delivery of this non-covered care.   50.5 - ABN Standards                                                                                (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21)  The ABN, Form CMS -R-131, is the OMB approved standard written notice.  Failure to use this notice as mandated could result in the  notice being invalidated and/or the notifier being held liable for the items or services in question.  The online replicable copies of the OMB approved ABN (CMS -R-131) and instructions for notice completion are available on the CMS website at:  http://www.cms.gov/Medicare/Medicare -General - Information/BNI/ABN.html  A. Language  Choice    The ABN is available in English and Spanish under a dedicated link on the web page given above.  Notifiers should choose the appropriate version of the ABN based on the language the beneficiary best understands.  Insertions must be in English when the Engl ish language ABN is used.  Similarly, when a Spanish language ABN is used, the notifier should make insertions on the notice in Spanish, if applicable.  In addition, verbal assistance in other languages may be provided to assist beneficiaries in understanding the document.  However, the printed document is limited to the OMB -approved English and Spanish versions.  Notifiers should document any types of translation assistance that are used in the Additional Information section of the notice.   B.  Effective Versions
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B.  Effective Versions   ABNs are effective as of the OMB approval or expiration date given at the bottom of each notice.  The routine approval is for 3 -year use.  Notifiers are expected to exclusively use the current version of the  ABN.  CMS will allow a transition period for he althcare providers and suppliers to switch from using expiring notices to newly approved notices.   C. General Notice Preparation Requirements
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Number of Copies  A minimum of two copies, including the original, should be made so the beneficiary and notifier each have one.  The notifier should retain the original whenever  possible.  Reproduction  Notifiers may reproduce the ABN by using self -carbonizing paper, photocopying, digitized technology, or another appropriate method.  All reproductions should conform to applicable requirements.  Length and Size of Page  The ABN form must not exceed one page in length; however, attachments are permitted for listing additional items and services.  If attachments are used, they should allow for clear matching of the items or services in question with the reason and cost esti mate information.  The ABN is designed as a letter - sized form.  If necessary, it may be expanded to a legal -sized  page.  Contrast of Paper and Print  A visually high -contrast combination of dark ink on a pale background should be used .  Do not use reversed print (i.e. white print on black paper), or block -shaded (highlighted)  text.  Font  Fonts as they appear in the ABN downloaded from the CMS web site should be used.  In cases where changes need to occur, notifiers should use alternative fonts that are easily readable, such as Arial, Arial Narrow, Times New Roman, and Courier.   Any other changes to the font, such as italics, embossing, bold, etc., should not be used since they can make the ABN more difficult to read.  The font size generally should be 12 point.  Titles should be 14 -16 point, but insertions in blanks of the ABN ca n be as small as 10 point if needed.  Information inserted by notifiers in the blank spaces on the ABN may be typed or legibly hand -written.  Customization  Notifiers are permitted to do some customization of ABNs, such as pre -printing information in certain blanks to promote efficiency and to ensure clarity for beneficiaries.  Notifiers may develop multiple versions of the ABN specialized to common treatment scenarios, using the required language and general formatting of the ABN.   Blanks (G) -(I) must be completed by the beneficiary when the ABN is issued and should not be pre -filled.  Lettering of the blanks (A- J) should be removed prior to issuance of an  ABN.  If pre -printed information is used to describe items/services
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when the ABN is issued and should not be pre -filled.  Lettering of the blanks (A- J) should be removed prior to issuance of an  ABN.  If pre -printed information is used to describe items/services and/or common reasons for non -coverage, the notifier must clearly indicate on the ABN which portions of the pre - printed information are applicable to the beneficiary  Healthcare providers or suppliers who pre-print a menu of items or services may wish to list a cost estimate alongside each item or service.   Modification  The ABN may not be modified except as specifically allowed by these instructions.  Notifiers must exercise caution before adding any customizations beyond these guidelines, since changing ABNs too much could result in invalid notice and healthcare provider or supplier liability for non -covered charges.  Validity judgments are generally made by Medicare contractors, usually when reviewing ABN -related claims; however, any complaints received may be investigated by contractors and /or CMS central or regional offices.
(Medicare Claims Processing Manual)
50.6 - Completing the ABN                                                                        (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21) Step-by-step instructions for notice completion are posted along with the notice on the CMS website and can be downloaded via this link:  http://www.cms.gov/Medicare/Medicare -General -Information/BNI/ABN.html   A. Other Considerations During ABN Completion   1.  Beneficiary Changes His/her Mind   If after completing and signing the ABN, a beneficiary changes his/her mind, the notifier should  present the previously completed ABN to the beneficiary and request that the beneficiary annotate the original ABN.  The annotation must include a clear indic ation of his/her new option selection along with the beneficiary's signature and date of annotation.  In situations where the notifier is unable to present the ABN to the beneficiary in person, the notifier may annotate the form to reflect the beneficiary's new choice and immediately forward a copy of the annotated notice to the beneficiary to sign, date, and return.   In both situations, a copy of the annotated ABN should be provided to the beneficiary as soon as possible.  If a related claim has been filed, it should be revised or cancelled if necessary to reflect the beneficiarys new choice.   2.  Beneficiary Refuses to Complete or Sign the Notice   If the beneficiary refuses to choose an option and/or refuses to sign the ABN when required, the notifier should annotate the original copy of the ABN indicating the refusal to sign or choose an option and may list witness(es) to the refusal on the notice although this is not required.  If a beneficiary refuses to sign a properly delivered ABN, the notifier should consider not furnishing the item/service, unless the consequences (health and safety of the patient, or civil liability in case of harm) are such  that this is not an option.  In any case, the notifier should provide a copy of the annotated ABN to the beneficiary, and keep the original version of the annotated notice in the patients file.
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In any case, the notifier should provide a copy of the annotated ABN to the beneficiary, and keep the original version of the annotated notice in the patients file.   50.7 - ABN Retention                                                                                 (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21) The notifier should retain the ABN delivered to the beneficiary on file should there be any question regarding whether the beneficiary had knowledge of the potential financial liability.    In certain situations, such as delivery by fax, the notifier may not have access to the original document upon signing.  Retention of a copy of the signed document would be acceptable in specific cases such as this.   In a case where the notifier that gives an ABN is not the entity that ultimately bills Medicare for the item or service (e.g. when a physician issues an ABN, draws a test specimen, and sends it to a laboratory for testing), the notifier should give a copy of the signed ABN to the billing entity.    In general, it is 5 years from discharge/completion of delivery of care when there are no other applicable requirements under State law.  Electronic retention of the signed paper document is acceptable.  Notifiers may scan the signed paper or wet version  of the ABN for electronic medical record retention and if desired, give the paper copy to the beneficiary.     50.8 - Effective ABN Delivery                                                                    (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21)  ABN delivery is considered to be effective when the ABN is:   1. Delivered by a suitable notifier to a capable recipient and comprehended by that recipient.   2. Provided using the correct OMB approved notice with all required blanks  completed.  Failure to use the correct notice may lead to the notifier being found liable since the burden of proof is on the notifier to show that knowledge was conveyed to the beneficiary according to CMS instructions.  3. Delivered to the beneficiary in person if  possible.   4. Provided far enough in advance of delivering potentially non- covered items or services to allow sufficient time for the beneficiary to consider all available options.
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3. Delivered to the beneficiary in person if  possible.   4. Provided far enough in advance of delivering potentially non- covered items or services to allow sufficient time for the beneficiary to consider all available options.   5. Explained in its entirety, and all of the beneficiarys related questions are answered timely, accurately, and completely to the best of the notifiers  ability.   The notifier should direct the beneficiary to call 1- 800-MEDICARE if the beneficiary has questions s/he cannot answer.  If a Medicare contractor finds that the notifier refused to answer a beneficiarys inquiries or direct them to 1- 800-MEDICARE, the notice delivery will be considered defective, and the notifier will be held financially liable for non- covered care.   6. Signed by the beneficiary.  A. Period of Effectiveness/Repetitive or Continuous Non -covered Care   An ABN remains effective after valid delivery so long as there has been no change in:    Care from what is described on the original ABN;   The beneficiarys health status which would require a change in the subsequent treatment for the non -covered condition; and/or   The Medicare coverage guidelines for the items or services in question (i.e., updates or changes to the policy of an item or service).   NOTE:   If any of the above changes during the course of treatment, a new ABN must be issued.  For items or services that are repetitive or continuous in nature, notifiers may issue another ABN to a beneficiary after one year for subsequent treatment for the non-covered condition.  However, this is not required unless any of the conditions described above apply to the given situation.   Notifiers may give a beneficiary a single ABN describing an extended or repetitive course of non -covered treatment provided that the ABN lists all items and services that the notifier believes Medicare will not cover.  If applicable, the ABN must also spec ify the duration of the period of treatment.  If during the course of treatment additional non-covered items or services are needed, the notifier must give the beneficiary another ABN.
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If a beneficiary is receiving repetitive non -covered care, but the healthcare provider or supplier failed to issue an ABN before the first or the first few episodes of care were provided, the ABN may be issued at any time during the course of treatment.  H owever, if the ABN is issued after repetitive treatment has been initiated, the ABN cannot be retroactively dated or used to shift liability to the beneficiary for care that had been provided before ABN issuance.  In cases such as this, care that was provi ded before ABN delivery would be the financial responsibility of the healthcare provider or supplier.  B. Incomplete ABNs   Allegations of improper or incomplete notices will be investigated by Medicare contractors.  If the notifier is found to have given improper or incomplete notice, the applicable Medicare contractor will not hold the beneficiary liable in the individual case.   C. Electronic Issuance of the ABN   Electronic issuance of ABNs is not prohibited.  If a healthcare provider or supplier elects to issue an ABN that is viewed on an electronic screen before signing, the beneficiary has the option of requesting paper issuance over electronic if that is what s /he prefers.  Also, regardless of whether a paper or electronic version is issued and regardless of whether the signature is digitally captured or manually penned, the beneficiary should be given a paper copy of the signed ABN to keep for his/her own recor ds.    50.8.1- Options for Delivery Other than  In-Person  (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21)  ABNs should be delivered in- person and prior to the delivery of medical care which is presumed to be non- covered.  In circumstances when in -person delivery is not possible, notifiers may deliver an ABN using another method.  Examples include:    Direct telephone contact;   Mail;  Secure fax machine; or   Internet e -mail.   All methods of delivery require adherence to all statutory privacy requirements under HIPAA.  The notifier must receive a response from the beneficiary or his/her representative in order to validate delivery.
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All methods of delivery require adherence to all statutory privacy requirements under HIPAA.  The notifier must receive a response from the beneficiary or his/her representative in order to validate delivery.   When delivery is not in- person, the notifier must verify that contact was made in his/her records.  In order to be considered effective, the beneficiary should not dispute such contact.  Telephone contacts should be followed immediately by either a hand- delivered, mailed, emailed, or a faxed notice.  The beneficiary should sign and retain the notice and send a copy of this signed notice to the notifier for retention in the patients record.   The notifier must keep a copy of the unsigned notice on file while awaiting receipt of the signed notice.  If the beneficiary does not return a signed copy, the notifier should document the initial contact and subsequent attempts to obtain a signature in appropriate records or on the notice itself.  50.9 - Effects of Lack of Notification, Medicare Review and Claim Adjudication                                                                                               (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21)  A.  Beneficiary Liability   A beneficiary who has been given a properly delivered ABN and agrees to pay may be held liable.  The charge may be the healthcare provider or suppliers usual and customary fee for that item or service and is not limited to the Medicare fee schedule.  If t he beneficiary does not receive proper notice when required, s/he is relieved from liability.   Notifiers may not issue ABNs to shift financial liability to a beneficiary when full payment is made through bundled payments.  In general, ABNs cannot be used where the beneficiary would otherwise not be financially liable for payment for the service beca use Medicare made full payment.   B. Healthcare Provider or Supplier Liability   A notifier will likely have financial liability for items or services if s/he knew or should have known that Medicare would not pay and fails to issue an ABN when required, or issues a defective ABN.  In these cases, the notifier is precluded from collecti ng funds from the beneficiary and is required to make prompt refunds if funds were previously collected.  Failure to issue a timely refund to the beneficiary may result in sanctions.