Re: determination on continued stay.

[Caralyn Davis]

Callie and others:   In the interests of spreading the word, I'll provide everyone with a brief preview of the story I am working on for Postacute Payment Report:   Yes, the BNI web site where the form is posted says that SNFs MAY begin using immediately. But Section 70 of Chapter 30 of the Claims Processing Manual definitively spells out that it replaces the notice of noncoverage in Part A situations involving lack of medical necesity or lack of a skilled level of care, and technically the SNFABN is already a requirement, according to a CMS official I spoke with this week. In fact, this requirement was technically effective Oct. 1, despite the fact that the SNFABN form was not even available Oct. 1. However, enforcement of this requirement will not occur until early 2004 to give providers time to introduce it, according to the CMS official, who recommended that providers implement by year-end at the latest. Also, in early 2004, CMS expects to allow public comments on the SNFABN; it is a model form so people will have an opportunity to make their opinions of the form known. (ALL BOLDING BELOW IS ADDED BY ME!)   When to use under Medicare Part A From the manual:   "A SNFABN is a CMS-approved model written notice that the SNF gives to a Medicare beneficiary, or to her or his authorized representative, before extended care services or items are furnished, reduced, or terminated when the SNF, the UR entity, the QIO, or the Medicare contractor believes that Medicare will not pay for, or will not continue to pay for, extended care services that the SNF furnishes and that a physician ordered 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); or     * Custodial care ("not a covered level of care") - �1862(a)(9)."   The SNFABN applies only to these two circumstances under Part A. There is yet another ABN for Part B services.   Other Part A noncoverage issues: Many facilities have historically issued Part A notices of noncoverage for technical denials, for example, when the person doesnt meet the three-day hospital stay requirement. The SNFABN does not apply in such circumstances. It is only to be used in the two scenarios listed above. I have to talk to yet another person at CMS to determine whether that means that SNFs still should issue a notice of noncoverage in such instances as failing to meet three-day hospital stay or whether they should not issue any notice at all if the scenario doesn't involve medical necessity or a noncovered level of care.   Section 70 of the chapter 30  of the Claims Processing Manual has all available instructions at this point. http://www.cms.gov/manuals/104_claims/clm104c30.pdf   Within that section, 70.4 explains how to complete the form itself. Examples of "proper denial paragraphs" are found in 70.4.5.   According to the rules as they are now:   "� If the patient selects Option 1, the patient may receive the subject extended care items or services, for which a demand bill must be submitted to Medicare for an official determination. �If the patient selects Option 2 the patient has elected not to receive the subject extended care items or services."     Also, this is interesting:   "Whether a SNFABN should be given in a particular instance depends on the SNF�s expectation of Medicare payment or denial for extended care services that it furnishes. �If the SNF expects Medicare to pay, a SNFABN should not be given. �If the SNF "never knows whether or not Medicare will pay," a SNFABN should not be given. �If the SNF expects Medicare to deny payment, the next question is: "On what basis is denial expected?""     Kind of suggests everyone better understand medical necessity and a covered level of care very very well.   I have alerted both AAHSA and AHCA to the situation.   --Caralyn Davis, Editor, Postacute Payment Report       ----- Original Message ----- From: Callie Larson To: [EMAIL PROTECTED] Sent: Friday, November 21, 2003 8:37 AM Subject: RE: determination on continued stay. I agree with the other posted comments: this form does not apply to the situations that we usually have at our facility.   I am having trouble finding the chapter 30 section 40 and 70 that are referred to. The link takes us to the Medicare Claims Processing Manual.  What appears to be Chapter 30 has sections indicated by decimals.  There is a 30.4 but no 30.7.  Section 30.4 is about PPS coding for ancillary services.  What am I missing?    I did find information about the SNFABN in the CMS Beneficiary Notices Initiative (BNI).  With reference to the SNFABN (fCMS-10055) the BNI states, "The model form CMS-10055 is a new SNFABN form for use by SNFs.  SNFs may begin to use the new SNFABN form immediately."  This implies that we also may choose not to use it!  It might be useful in situations where a specific treatment or procedure is recommended by the MD and it will not be covered by  Medicare.  This form does not seem useful for a standard cut letter since it does not present the option of a demand bill.  Has the demand bill option changed?    Theresa A Lang <[EMAIL PROTECTED]> wrote: The entire non-coverage letter form and process changed on 10-1-03 with the issuance of the CMS Electronic manual system. The new required form CMS 10055 can be found in the CMS Claims Processing Manual, Chapter 30, Sections 40 and 70. It is about 30 pages total and is a significant change from the old non-coverage letters found in the SNF 12 Manual. http://cms.hhs.gov/manuals/104_claims/clm104index.asp from this site select Chapter 30- then go to sections 40 and 70 I did attach a pdf copy of the CMS 10055 Theresa Lang Specialized Medical Services, Inc Milwaukee WI -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] Behalf Of Sue Junot Sent: Thursday, November 20, 2003 1:52 PM To: [EMAIL PROTECTED] Subject: determination on continued stay. sorry but I am bain dead today. can someone please direct me to INFORMATION covering "DETERMINATION ON CONTINUED STAY,DETERMINATION OF NONCOVERAGE,AND DETERMINATION ON ADMISSION" THANKS, SUE, RAC-C _________________________________________________________________ Say �goodbye� to busy signals and slow downloads with a high-speed Internet connection! Prices start at less than $1 a day average. https://broadband.msn.com (Prices may vary by service area.) /---------------------------------------------------------- The Case Mix Discussion Group is a free service of the American Association of Nurse Assessment Coordinators "Committed to the Assessment Professional" Be sure to visit the AANAC website. Accurate answers to your questions posted to NAC News and FAQs. For more info visit us at http://www.aanac.org -----------------------------------------------------------/ > ATTACHMENT part 2 application/pdf name=SNF ABN 11-03.pdf   Caroline Larson, RN, MS, RAC-C MDS/PRI Coordinator Fairport Baptist Homes, Fairport, NY 14450   Do you Yahoo!? Free Pop-Up Blocker - Get it now