Harmony Healthcare International (HHI) Blog

Medicare Denial Notices: The 4 Letters You Need to Know

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


stethoscope-paperwork.jpgWhat is hot this week?  Denial Notices. The process can be confusing and as a result, lead to non-compliance. Let me keep this blog simple and to the point. There are 4 important letters that you and your team need to know:

  1. The Generic Notice (form CMS-10123)

    The Generic Notice (form CMS-10123), officially called the Notice of Medicare Provider Non-Coverage, is given to all Medicare beneficiaries when the provider makes the determination that the services no longer meet Medicare Coverage Criteria.    The Generic Notice should be delivered no later than two days before the date of the end of coverage to Medicare Part A, Medicare Advantage beneficiaries and Medicare Part B therapy services.

    Through this expedited determination process, beneficiaries may obtain a QIO review, a provider’s decision to discharge them, or end all their covered care, for medical necessity reasons.  If the beneficiary disagrees with the provider’s determination, the beneficiary follows the instructions provide to contact the QIO and request an expedited review.   The QIO is responsible for establishing contact with the provider to notify them of the appeal and request medical record documentation to assist in the review.  The provider must then give a second “detailed” notice using CMS form 10124 to explain the reason for the determination of non-coverage and outlining the specific regulations used to make this determination. 

  2. SNFABN (CMS 10055) or SNF Denial Letters: SNF Advance Beneficiary Notice

    The traditional denial letter, or SNF Advance Beneficiary Notice (SNF ABN), is given in addition to the Generic Notice to any beneficiaries who remain in the facility in the facility receiving non covered care at the conclusion of a Medicare Part A covered stay. The SNF provider may use either the SNFABN (CMS 10055) or one of the Denial Letters (from CMS’ website) for Medicare skilled services to issue this notice.  The purpose of this letter to give the resident the opportunity in writing to request that the SNF submit a demand bill to the Medicare Administrative Contractor (MAC) before the receiving physician-ordered services that are non-covered due to a lack of medical necessity or because the services are custodial care.

    The notice must specify the items or services that have been determined to be non-covered, the reason for the determination and the estimated cost of the services to enable the beneficiary to make an informed decision about receiving the services in question.

    The ABN must be verbally reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed. The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice.

    When the demand bill option is selected by checking option 1 on the form a copy of the form should be provided to the business office to notify them of the need to complete and submit the demand bill.

  3. FFS ABN (CMS R-131): Fee For Service Advanced Beneficiary Notice

    Skilled Nursing Facilities (SNFs) must use the FFS ABN for items and/or services expected to be denied under Medicare Part B only.  This includes Part B therapy services, wound care supplies and ongoing repetitive laboratory tests. 

  4. Notice of Exclusion from Medicare Benefits (NEMB SNF)

    The Notice of Exclusion from Medicare Benefits - Skilled Nursing Facility (NEMB SNF) may be used with extended care item(s) and service(s) that are not Medicare benefits. NEMB-SNFs alert Medicare beneficiaries in advance that Medicare does not cover certain extended care item(s) and/or service(s) because the item or service does not meet the definition of a Medicare benefit or because the item or service has been specifically excluded by law. This is a voluntarily notice that Harmony Healthcare International (HHI) recommends facilities provide to residents.

    Examples of scenarios:
    • No 3-day qualifying hospital stay.
    • The resident was not admitted to the skilled nursing facility within 30 days of his/her hospital discharge.
    • SNF Transfer requirements not met.
    • No benefits from Medicare (Patient does not have Part A).
    • Patient has used the 100-day benefit from Medicare and has “Exhausted the Benefit”. 

Beneficiary Notices Initiative Website or BNI Website is located at www.cms.hhs.gov/bni.  The BNI website provides information on financial liability notices, including the Revised ABN, SNFABN and SNF Denial Letters, Expedited Determination Notices and NEMB-SNF, and provides instruction for issuing each type of notice.  Harmony Healthcare International (HHI) recommends bookmarking the following links in order to reference the most up to date data released by CMS:

www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html

If you need assistance with denials, please contact us by clicking here or calling our office at (800) 530-4413. 


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Topics: Medicare Denial Notices


Kris Mastrangelo, OTR/L, LNHA, MBA

WRITTEN BY

Kris Mastrangelo, OTR/L, LNHA, MBA
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