Harmony Healthcare Blog

Notice of Medicare Non-Coverage (NOMNC) Advance Beneficiary Notice of Non-Coverage (SNFABN) Part V

Posted by Kris Mastrangelo on Tue, Jul 03, 2018


Edited by Kris Mastrangelo

C.A.R.E.

Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency


Elder man has not enough money for drugsA continuation of the SNF ABN discussion leads to higher perspective on the letter process.  One of 3 entities (SNF, UR, or QID/Medicare Contractor) is responsible for administering a written notification: 

  1. 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.
  1. The UR 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. 
  1. 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 QIO’s decision of the non-coverage. 

The SNF ABN is given to a Medicare Beneficiary when the facility feels the services will not be paid for by Medicare.  The SNF ABN is the paper trail depicting that the beneficiary was notified of the financial liability. 

The initiation, reduction or termination of expected unpaid care items or services, are considered triggering events. 

The following describe the three triggering events for a SNF ABN: 

  1. An Event Description is a 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. 
  1. A Reduction is when 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 SNF ABN to the beneficiary before it reduces items or services to the beneficiary.
  1. A Termination is when 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. 

Just to reiterate, the facility issues a SNF ABN when: 

  • An item or service that is usually paid for by Medicare, may not be paid for because it is not medically reasonable and necessary; or
  • Custodial Care

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A very important component to understand is that the facility does not need to issue a SNF ABN when care or items are 

  • reduced or terminated in accordance with a physician’s order,
  • where a physician does not order the items or services at issue, or
  • where the physician agrees in writing with the SNF’s, the UR entity’s, the QIO’s, or the Medicare contractor’s assessment that the extended care items or services are not necessary. 

All reductions or discontinuation of therapy is based on a physician order. 

Given the significant amount of correspondence on this subject matter, there will be 2 additional blog posts on SNF ABN & NOMNC letters.

Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have.  You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 


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Tags: Denial Letters

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