ABNs

Advanced Beneficiary Notice

Notices are required

  1. When a resident would otherwise be eligible for Medicare benefits, but facility has determined they do not need or they do not qualify for Medicare skilled care based on clinical reasons – this is when we have to give written notice.
  2. You are only required to give notice if the resident is eligible for Medicare A stay or Medicare B therapy.
  3. We do not have to give notice if they are not eligible or do not have Medicare days available (have exhausted 100 days).

Admission Notices:

  1. NEMB: Notice of Exclusion from Medicare Benefits – SNF: give this if

*no 3 day qualifying stay

*no Medicare bed available

*resident waives Medicare coverage

  1. SNF ABN: give this is

*Resident has Medicare A, and

*Has Medicare A days available (benefit not exhausted), and

*Has had 3 day qualifying stay, but

*Does not require skilled care

Discharge from Medicare Services:

  1. Discharge from Skilled Services – Medicare A: SNF ABN and the Expedited Notice of Non-Coverage (form 10123)

*The decision to discharge from Medicare A made by clinical staff. The SNF

ABN must give a clinical reason. Use reasons from list given.

  1. Discharge from Medicare B Therapy Services: ABN 131 form and Expedited Notice of Non-Coverage (form 10123)

*Decision to discharge from therapy is made by therapy staff

*The ABN should include the clinical reason for ending therapy

*These notices come from therapy department

  1. Reduction of Therapy Services: ABN 131 is given

*Notice is given when therapy reduces one or all therapy services.

Delivery of Notices:

  1. SNF ABN should be given in person, explained, then signed by resident or resp party.
  2. If you cannot give the notice in person, you may via phone, mail, fax, or e-mail. You must verify contact was made in your records.
  3. Resident or resp party should not be able to dispute that notice was given.
  4. Telephone contacts must be followed up with hand-delivered, mailed, e-mailed, or faxed notice. You have to read the entire notice to the resident or resp party over the phone. They then have to sign the notice they receive and return it to you. Save the notice in file until you receive the signed one back. Good idea to have a witness and have witness sign your documentation as well.
  5. You must make attempts to get the signature and document your attempts to get a signed notice.
  6. Notice must be delivered to a person capable of understanding it! If the resident cannot understand it, you have to give notice to the resident’s legal rep – has to be POA or Guardian. Copy goes to resident or resp party and copy in resident file.
  7. Notice must be sent no less than 2 full days prior to the day you will terminate the Skilled Care or reduce Part B therapy.
  8. If resident or legal rep refuse to sign, make note of that, documentation circumstances, have all witnesses sign – verifying your attempt to deliver.

Expedited Determination: Detailed Explanation of Non-Coverage form 10124

  1. After giving notice to resident, they have the right to contact the QIO to appeal the decision.
  2. Quality Improvement Organization will contact facility and ask you to send the 10124 form, which provides additional information.

Technical Requirements for Forms: Always make sure you have most current version

  1. SNF ABN: 10005 form

*Must be one page only

*Must use 12 pt. font and no bolding or highlighting

*The top of the form must include facility name, address, and phone number

*Must insert the resident’s full name and Medicare # as it appears on the

Medicare card

*You must give them a good faith estimate of the cost

  1. CMS 10123 and 10124:

*Must be in exact form as provided by CMS, printed as two-sided document

*All blanks must be completed with 12 pt font

  1. ABN: CMS R-131

*Comes from therapy department

*Estimated cost must be accurate

*Actual charges for therapy services should be inserted by therapy company.