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 -----
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
