SNF Advance Beneficiary Notices

If you would like more information about this topic or any other topic contact Barbara Stegun Phair, Esq.

In its transition to an internet manual system, CMS has made changes to the Skilled Nursing Facility ("SNF") manual.  One of the major changes that CMS has made is to replace the SNF notices of non-coverage previously used for Part A PPS residents with the implementation of the SNF Advance Beneficiary Notice ("SNF ABN").

Instead of the five different versions of the notice of non-coverage that facilities have been using, CMS developed one model form, CMS-10055, for facilities to use to provide notice to traditional Medicare Part A residents when the SNF, utilization review entity, quality improvement organizations ("QIO"), or Medicare contractors 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 because the services are not reasonable and necessary or not a covered level of care ("custodial care").  The form is available on the CMS website at  www.cms.hhs.gov/medicare/bni) and is not to be modified.  Instructions with regard to the completion and delivery of the SNF ABN, which previously had been included in Sections 357 and 358 of the SNF manual, can now be found in Sections 40 and 70 of Chapter 30 of the Medicare Claims Processing Manual (Pub. 100-4).

The CMS-10005 is for Medicare Part A residents only.  Another ABN form, CMS-131,  must be used by the facility to give notice when a resident is no longer eligible for Part A benefits and Medicare is expected to deny payment for Part B covered services that the facility furnishes, either directly or under arrangement.  (Chapter 30 of the Claims Processing Manual explains the basic requirements for Part B ABNs (Section 50) and specific information with regard to limits of liability and DMEPOS (Section 130  and 150, respectively).

Additionally, CMS recently introduced another ABN form, the Notice of Medicare Non-Coverage (CMS-10095-A) that is to be used for Medicare managed care patients. As of January 1, 2004, based on the Medicare managed care entity's determination of when services should end, a facility is responsible for delivering the Notice of Medicare Non-Coverage at least 2 days before the first non-covered day of service.  Form instructions are available at http://www.cms.hhs.gov/medicare/bni.