Harmony Healthcare International (HHI) Blog

Question and Answer: NOMNC and SNFABN: Part II

C.A.R.E.

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


Wooden Blocks with the text Faqs

Question and Answer

Question and Answer with Sally Fecto Sr. VP Field Operations Harmony Healthcare International (HHI)

  1. When do you give the NOMNC and the ABN at the same time?

    You give both the NOMC and the SNF ABN when denying Medicare Part A coverage with days available and the patient is staying in the facility. 
  1. When would you give one and not the other?

    You would give the NOMNC only when a resident has skilled benefit days remaining and is being discontinued from Part A services and is leaving the facility. 
  1. A Skilled Medicare Part A patient with stage IV pressure ulcer and daily skilled wound care has discontinued PT and OT and will remain skilled under their Medicare A benefits for the skilled wound care. There is conversation that the SNF ABN must be provided to the patient who is discharging from PT and OT and remining on skilled Medicare for the daily skilled direct skilled nursing services.

    The SNF ABN is not given in this instance.  The SNF ABN is only given in situations where the resident remains in the facility receiving non-covered care at the conclusion of Medicare Part A coverage. This scenario has the resident continuing with skilled nursing. As long as the beneficiary is still receiving Medicare Part A covered care, the SNF ABN is not appropriate. 

    SNFs do not issue a SNF ABN to transfer financial liability to the beneficiary (Transmittal 4011 of March 30, 2018).

    When extended care items or services 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.
    In the case described:  The physician orders discontinuation of PT and OT.  Skilled care continues. 

    Base on the above, the SNF ABN would not be issued due to termination of therapy and remaining skilled coverage for nursing. 
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  1. Is the NOMNC issued when Part B therapy ends for both inpatients and outpatients?

    The Notice of Medicare Non-Coverage (NOMNC) is provided to all Medicare beneficiaries:  Medicare Part A, Medicare Part B, Medicare Advantage Part A/Part B. 
    • Outpatient in the nursing home applies to Medicare Part B therapy services.  Long term care residents of a nursing home are receiving Medicare Part B outpatient therapy.
    • The NOMNC is required 2 days before coverage ends to afford the patient opportunity for an expedited appeal or fast track appeal with the BFCC-QIO. 
  1. Is the Part B SNFABN applicable to both inpatients and outpatients?

    The SNF ABN applies to the Medicare Part A beneficiary and not the outpatient/Medicare Part B patient. 
    • A Medicare Part B patient would receive an ABN
    • The SNF ABN does not apply to Managed Medicare Plans, only traditional or Fee for Service Medicare
    The Provider must issue a liability notice to Original Fee-For-Service (FFS) Medicare beneficiaries before the SNF provides an item or service that is usually paid for by Medicare, but may not be paid for in this particular instance because it is not medically reasonable and necessary, or custodial care.  
    • SNF’s must use the SNF ABN (Form CMS-10055) is provided when ending Medicare Part A items and services.
    • SNFs must use the Advance Beneficiary Notice of Non-coverage (ABN), Form CMS-R-131 for Medicare Part B items and services.

CMS language refers to inpatient and outpatient.  These notices are used in other settings such as labs, physician offices, hospice, etc. 

  1. What happens when a resident has a 3-day Qualifying Hospital Stay and is appropriate for therapy, but refuses services for 3 days. The patient does not fall in a presumption of coverage RUG. Can we say “due to the patient’s refusal, he/she is not eligible to bill Medicare” and is contact guard assistance from day of entry? Or do we need to still give 48 hours’ notice and have 5 days billed at MR with no skill?

    General Response:   The provider cannot give a retroactive notice.  The patient was admitted under Medicare benefits. Once the team determines the patient is “not at a skilled level of care,” the 2-day notice is required with the NOMNC and the SNF ABN provided. 

    The SNF ABN is required to provide the beneficiary with financial information to make an informed decision.

    Patient specific details are important.  Ask the team these pertinent questions:
    • Why was the patient hospitalized for a 3-day qualifying stay? 
    • If the patient refused, what does the team believe as medically necessary therapy over the first 3 days, why?
    • Has the patient been informed that coverage is at risk? 
    • Has the family, if appropriate, and physician discussed the refusals with the patient?
    • Will the patient participate in therapy on days 4-8?  This equates to 5 days and a skilled level of care on day 8.
    • Was an ARD selected potentially to code services from hospital such as IV Fluids? 

Complete the 5-Day MDS, issue notices NOMNC and SNF ABN as appropriate and bill that RUG for the days utilized.  A lower 14-RUG Level does not support the presumption of coverage through the ARD, however, a lower 14 RUG Level does not necessarily deem the patient unskilled.  

The below table offers various scenarios. 

Scenario

NOMC

 ABN  

Notice(s)

Resident has skilled benefit days remaining and is being discontinued from Part A services and is leaving the facility immediately following the last covered skilled day.

Yes

No

NOMNC Only

Resident has skilled benefit days remaining and is being discontinued from Part A services and will continue living in the facility.

Yes

Yes

Both

Resident has skilled benefit days remaining and elects the Hospice Benefit, but the coverage criteria for dual eligibility for Part A skilled and Hospice are not met.

No

No

Notices
Not Required

Resident discharges self from the facility as an unplanned discharged.

No

No

Notices
Not Required

Resident has an unplanned discharge to the hospital.

No

No

Notices
Not Required

Resident discharges to another SNF for continued skilled care.

No

No

Notices
Not Required

Resident exhausts their skilled Part A benefit (no days remaining).

No

No

Notices
Not Required

 

Our next blog post, Part III of V, provides further details around the clarification of requirements for administering the Notice of Medicare Non-Coverage (NOMNC). 

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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Topics: Denial Letters

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