RE: Denial Notices

[Joanne Stutesman]

Title: Message

Thanks Corey, this should answer my questions. -----Original Message----- From: Corey [mailto:[EMAIL PROTECTED] Sent: Tuesday, December 02, 2003 1:38 PM To: [EMAIL PROTECTED] Subject: Re: Denial Notices Here's the latest:   This one was from Rena on 7/2003:   >>>Denial letters, also called notice of noncoverage letters, are issued either on admission if the resident is to receive no Medicare Part A coverage or after skilled services end as a result of the resident meeting goals or plateauing, etc.  Denial letters (other than admission denials) are to be issued on the last day of skilled services. Read up on denial letters in the Medicare SNF Manual (Pub 12) Section 356 at: http://cms.hhs.gov/manuals/12_snf/sn335.asp#_1_60 and at the Medicare Learning Network website at  http://cms.hhs.gov/medlearn/SNFFRManual.pdf page 20. Rena<<   Then there was a slight change:  (This notice was from Caralyn Davis on 11/14/03):   I decided to look at the new manual system to see what it said about notices of noncoverage, and I found a new Skilled Nursing Facility Advance Beneficiary Notice form. Section 70 in Chapter 30, "Financial Liability Protections," of the Medicare Claims Processing Manual (http://www.cms.gov/manuals/104_claims/clm104c30.pdf) explains when/how to use the form. The new SNFABN form itself is available at http://www.cms.hhs.gov/medicare/bni/ and according to that web site it is supposed to be implemented immediately. Am I the only one who missed CMS notifying facilities about this new form?-Caralyn   Introductory description in chapter 30:     70 - Form CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (Rev. 1, 10-01-03) A3-3730.1 Following are the standards for use by Skilled Nursing Facilities (SNFs) in implementing the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN, model Form CMS-10055) notice of noncoverage requirements. This section provides instructions, consistent with the skilled nursing facility prospective payment process (SNF PPS), regarding the notice that SNFs must provide to beneficiaries in advance of furnishing what SNFs, utilization review (UR) entities, quality improvement organizations (QIOs), or Medicare contractors believe to be noncovered extended care services or items or of reducing or terminating ongoing covered extended care services or items. The SNFABN replaces the SNF Notices of Non-Coverage previously used for notification purposes. SNFs must also meet the ABN Standards in �40.3 of the MCPM in completing and delivering SNFABNs. 70.1 - Basic Requirements for SNFABNs (Rev. 1, 10-01-03) 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). Except for the exclusions specified above, there is no other statutory authority on which the limitation on liability (LOL, �1879) provision applies to SNF claims denied. ----- Original Message ----- From: Joanne Stutesman To: [EMAIL PROTECTED] Sent: Tuesday, December 02, 2003 1:24 PM Subject: Denial Notices Could someone point me to the resource for denial notices?  Specifically, can they be dated/issued on the last covered day, or must they be issued prior to the LCD? Also, I had previously asked about denial notices on admission when the resident has no technical eligibilty, is a denial notice required on admission in that situation? Thanks for any advice, Joanne Stutesman