SNF Determinations of Non-Coverage Denial Letters, ABNs & Expedited Determinations

Transcription

1 SNF Determinations of Non-Coverage Denial Letters, ABNs & Expedited Determinations for clients of: Content developed and presented by: 3030 N. Rocky Point Drive, Suite 240 Tampa, FL

2 SNF Denial Notices Limited Copyright: November 2017 All materials are protected under the copyright laws. The limited copyright allows the purchaser to copy for use but not for distribution. FH28 - Developed by Polaris Group Page 1 of 73

3 SNF Denial Notices POST-TEST 1. The Generic Notice is given when: a. When all Medicare benefits are ending during a continued Part A stay b. At time of admission c. When Part A benefits are exhausted d. None of the above 2. Which of the following does NOT apply to the SNFABN? a. Must be provided timely b. The form may be revised in its entirety c. It replaces all 3 of the current SNF determination notices d. The notice must be understood and comprehended by the beneficiary 3. Which of the following applies: a. Generic Notice must be issued by last covered day b. Generic Notice and the SNF Determination of Continued stay cannot be issued at the same time c. Generic Notice gives information on an expedited review by an independent entity d. None of the above 4. Acceptable Generic Notices must include: a. Information on how to reach their QIO b. Must be issued two days prior to last covered day c. Must be signed by resident or authorized representative d. All of the above 5. A NEMB-SNF Notice of Exclusions from Medicare Benefits: a. Is given when the resident did not have a qualifying 3 day hospital stay. b. Is given when the 30 day transfer requirement is not met c. Is used to advise beneficiaries that Medicare will not pay for items or services provided. d. All of the above FH28 - Developed by Polaris Group Page 2 of 73

4 SNF Denial Notices POST-TEST ANSWERS 1. The Generic Notice is given when: a. When all Medicare benefits are ending during a continued Part A stay b. At time of admission c. When Part A benefits are exhausted d. None of the above A 2. Which of the following does NOT apply to the SNFABN? a. Must be provided timely b. The form may be revised in its entirety c. It replaces all 5 of the current SNF determination notices d. The notice must be understood and comprehended by the beneficiary B 3. Which of the following applies: a. Generic Notice must be issued on last covered day b. Generic Notice and the SNF Determination of Continued stay cannot be issued at the same time c. Generic Notice gives information on an expedited review by an independent entity d. None of the above C 4. Acceptable Generic Notices must include: a. Information on how to reach their QIO b. Must be issued two days prior to last covered day/effective date c. Must be signed by resident or authorized representative d. All of the above D 5. A NEMB-SNF Notice of Exclusions from Medicare Benefits a. Is given when the resident did not have a qualifying 3 day hospital stay. b. Is given when the 30 day transfer requirement is not met c. Is used to advise beneficiaries that Medicare will not pay for items or services provided. d. All of the above D FH28 - Developed by Polaris Group Page 3 of 73

5 SNFABN and Expedited Review Notices for Part A and Part B Services 1 Denial Letters/ABNs/Expedited Review SNFABN and NEMB Notices of Non-Coverage Expedited Review Notice Part B Notices Medicare Advantage Plans 2 FH28 - Developed by Polaris Group Page 4 of 73

6 Denial Letters/ABNs/Expedited Review Requirement for Notices F-tag 156: Resident Rights - Resident has right to request the facility submit the bill for appeal; determine if the facility submitted the bill to the Medicare Administrative Contractor (MAC) within the required timeframe. F-tag 492: Facility failed to submit the bill to the MAC within the required timeframe or charged the resident while the decision was pending. Will review records for notices; will ask to review any requests for demand bills. 3 Denial Letters/ABNs/Expedited Review Requirement for Notices 1. Notices of Non-coverage and right for a demand bill to be submitted to MAC for review The Limitation on Liability provision protects the beneficiary as well as the provider by requiring knowledge of coverage determinations before holding either liable 2. Requirement for Notification of Expedited Review by Quality Improvement Organization (QIO) 4 FH28 - Developed by Polaris Group Page 5 of 73

7 Generic Notices/Expedited Review/NOMNC Same timing requirements and forms apply to Part A & Managed Care; also used for Part B 5 NOMNC - Expedited Review Notice Benefits Improvement and Protection Act (BIPA) provides Medicare beneficiaries with a right to a fast track (within 72 hours) appeal by an independent organization known as a Quality Improvement Organization (QIO). QIOs have experience performing expedited reviews for managed care. This right is in addition to the right for a review by Medicare. The right to an expedited review does not eliminate the right to a demand bill. Applies to both Part A and certain Part B services and managed care. 6 FH28 - Developed by Polaris Group Page 6 of 73

8 Expedited (NOMNC) Review Notice EXPEDITED DETERMINATIONS; Notices of right to an expedited review by an independent entity: Two Expedited Determination Notices: 1. Notice of Medicare Provider Non-Coverage (NOMNC) CMS Required expedited determination notice Try to give the notice even if resident is going home and family or resident state they don t need it 7 8 FH28 - Developed by Polaris Group Page 7 of 73

9 9 Expedited (DENC) Review Notice 2. Detailed Explanation of Non-Coverage Notice (DENC) CMS Only issued if an appeal is requested Provides information to support the reason for the denial QIO uses information included on the notice when making a coverage determination No signature by resident is required on this form 10 FH28 - Developed by Polaris Group Page 8 of 73

10 11 12 FH28 - Developed by Polaris Group Page 9 of 73

11 When to Issue an Expedited Review Notice (NOMNC) Issue Expedited Review/NOMNC (CMS-10123) when resident is determined to not meet skilled criteria and the resident is being discharged from ALL Part A: Discharged from Part A services, but continues to reside in the facility under another payer source. Discharged from Part A, has remaining days, but is simultaneously being discharged from the facility. Where the resident has remaining SNF days available, continues to reside in the facility, and begins to receive services covered under Part B. Issue even if Medicare is secondary payer if all Medicare services are ending. 13 When NOT to Issue an Expedited Review Notice (NOMNC) Do NOT issue at time of admission to a SNF Do NOT issue when full 100 days are used up at exhaustion of benefits Do NOT issue when a resident is transferred to the hospital. Do NOT issue when resident is transferred to another SNF for SNF level of care NOT required for a Leave of Absence Do NOT issue for AMA Do NOT issue for reduction in some but not all skilled services If resident refuses therapy, and thus Skilled Care is ending, issue a notice 14 FH28 - Developed by Polaris Group Page 10 of 73

12 Expedited (NOMNC) Review Timing Expedited Review/NOMNC (CMS-10123): Must be issued no later than two days in advance of last covered day/effective date Can be issued earlier if last covered day/effective date is known, for example 3 days prior. Can be issued at admission if stay is expected to be less than two days. Regardless of when issued, the resident has up to noon of the day before the Effective date to request an appeal from the QIO. 15 Effective Date THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT {insert type} SERVICES WILL END: {insert effective date} DATE Insert the last day of covered services/last paid day Note: CMS published updated rules effective Aug FH28 - Developed by Polaris Group Page 11 of 73

13 Effective Date When a resident is ending Part A and staying in facility under another payer source. The Effective date is the last covered/paid day by Medicare. For example, the resident last covered day on Medicare is Friday, and on Saturday the payer source changes to Medicaid. Effective Date is Friday on NOMNC as last covered/paid day. No liability risk for resident that day 17 Effective Date When a resident is ending Part A and discharge from Part A is coordinated with discharge from SNF. The effective date is the last covered/paid day. Resident is covered and has no liability risk through Friday, last covered/paid day. The plan is to discharge off Part A and from SNF the next day, Saturday. There is no liability up to point of discharge from SNF 18 FH28 - Developed by Polaris Group Page 12 of 73

14 Effective Date When a resident is ending Part A and discharge from Part A is coordinated with discharge from SNF. Must be able to issue in Spanish if required or accommodate in another manner. No SNFABN is required if discharge from Part A and discharge is planned for the day after the effective date, however, if resident does not discharge as planned, issue a SNFABN to clearly articulate they are liable for that day. 19 Two days before effective date Timing WHEN THE LAST COVERED DAY IS: MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY ISSUE NOMNC NO LATER THAN THE DAY NOTED BELOW: SATURDAY (OR FRIDAY) SUNDAY (OR SATURDAY OR FRIDAY) MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY See Notice/Appeal Process 20 FH28 - Developed by Polaris Group Page 13 of 73

15 Procedures for Issuing NOMNC CMS usually requires that notification to a beneficiary who has been deemed legally incompetent be made to an authorized representative of the beneficiary. If beneficiary is temporarily incapacitated a person (typically, a family member or close friend) whom the provider has determined could reasonable represent the beneficiary, but who has not been named in any legally binding document, may be a representative for the purpose of receiving the notices. Referred to as an unnamed representative. 21 Procedures for Issuing NOMNC Issue in Person to Beneficiary or Legal Representative: Explain rights and get signature Give original to resident and copy for records May be issuing SNFABN at same time Dates will be the same Encourage QIO review as this review is better for resident and SNF 22 FH28 - Developed by Polaris Group Page 14 of 73

16 Procedures for Issuing NOMNC Issuing to unnamed representative in person or to any representative over phone: If issuing in person to an unnamed representative OR If unable to issue in person to any representative; then the provider should telephone the legal or unnamed representative to advise when the beneficiary s services are no longer covered. The beneficiary's appeal rights must be explained to the representative, and the name and telephone number of the appropriate Quality Improvement Organization (QIO) should be provided. 23 Procedures for Issuing NOMNC Provide all required information over the phone or in person to unnamed representative: Last covered day of service and when beneficiary s liability is expected to begin Right to appeal Describe how to request an appeal Deadline for appeal and what to do if deadline is missed Telephone number of QIO 24 FH28 - Developed by Polaris Group Page 15 of 73

17 Procedures for Issuing NOMNC The NOMNC must be annotated with the following information if contact is made by phone or if issuing in person to unnamed representative: Reflect all information was communicated to representative Representatives name/relationship Telephone number used (if over phone) Date and time of contact Name of staff person making contact 25 Procedures for Issuing NOMNC The date of the conversation is the date of the receipt of the notice Place the annotated copy of the notice in the beneficiary's file Mail copy of the annotated copy to the representative the same day the telephone contact was made The annotation serves as proof of receipt. 26 FH28 - Developed by Polaris Group Page 16 of 73

18 Procedures for Issuing NOMNC When direct phone contact cannot be made to review rights; send the notice to the representative by certified mail, return receipt requested: The date that someone at the representative s address signs (or refuses to sign) the receipt is the date of receipt. May want to send 3 days before Effective Date. When notices are returned by the post office, with no indication of a refusal date, then the beneficiary's liability starts on the second working day after the provider's mailing date FH28 - Developed by Polaris Group Page 17 of 73

19 Procedures for Issuing NOMNC If both the provider and the representative agree, providers may send the notice by fax or , however, providers fax and systems must meet the The Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy and security requirements. 29 Timing Plan ahead Issue two days before last covered day/effective date Issue Notices earlier i.e. 3 days early when possible Discharge planning part of daily stand-up and weekly meetings Be able to issue notices later in the day if needed Prepare packet for issuing prior to day issued 30 FH28 - Developed by Polaris Group Page 18 of 73

20 QIO Appeal FOLLOW QIO PROCEDURES FOR AN APPEAL Complete Detailed Notice CMS The audience is the QIO; so defend decision as to why SNF no longer feels resident qualifies for Skilled Part A coverage. Provide copy of Detailed Notice to both resident and QIO by the end of the business day 31 QIO Appeal Provide QIO copies of both notices Provide a copy of pertinent medical records Any records which support change in orders, change in services, or change in condition which may include condition has stabilized. The QIO performs reviews 7 days a week. Have a system to issue and receive notices on weekends. 32 FH28 - Developed by Polaris Group Page 19 of 73

21 QIO Appeal First, the QIO confirms the NOMNC is valid If not valid, the QIO will require the SNF to issue another notice that may delay the review. This must be done quickly, as the delay may extend the coverage for the resident to allow for another two days notice. Any days after original Effective Date, is the SNF s liability as the SNF cannot bill the resident nor can the SNF bill Medicare. 33 QIO Appeal The QIO must render a decision within 72 hours The decision will be conveyed by phone to the resident, SNF and physician followed by written notification hopefully before the resident becomes liable. Make sure the resident understand their liability risk The QIO decision is BINDING; the resident cannot request a DEMAND BILL 34 FH28 - Developed by Polaris Group Page 20 of 73

22 QIO Appeal The resident has a right to an expedited Reconsideration if the appeal is denied Only the resident can appeal decision, the SNF has no appeal rights The QIO manages the reconsideration that is performed by a Qualified Independent Contractor (QIC) a contracted agency that works with your QIO The expedited reconsideration must be requested by noon of the day following notification by the QIO decision. 35 QIO Appeal Extends Coverage: Extend coverage per QIO findings or for one week at a time Days approved by QIO cannot be denied later by MAC All new notices must be issued again when the SNF determines non-coverage in the future 36 FH28 - Developed by Polaris Group Page 21 of 73

23 QIO Appeal Usually they overturn in relation to timing of notice, pain management, more services needed, or no one at home to help them with getting to outpatient therapy If resident APPEALS the denial, continue with MDS cycle by opening MDS and setting ARD just in case needed for payment if denial is overturned For example, open an EOT pending appeal of the QIO denial 37 Denial Letters/SNFABN/NEMB 38 FH28 - Developed by Polaris Group Page 22 of 73

24 Denial Letters Requirement for Notices 1. Notices of Non-coverage and right for a demand bill to be submitted to MAC for review The Limitation on Liability provision protects the beneficiary as well as the provider by requiring knowledge of coverage determinations before holding either liable. 39 Denial Letters/SNFABN NOTICES OF NON-COVERAGE: OPTION ONE - SNFABN notices or OPTION TWO - Determination Letters 1. SNF Determination on Admission with notification of right to a demand bill 2. SNF Determination for Continued Stay with notification of right to a demand bill Both options inform a Medicare beneficiary, before he or she receives specified items or services that otherwise might be paid for, that Medicare certainly or probably will not pay for them on that particular occasion. 40 FH28 - Developed by Polaris Group Page 23 of 73

25 OPTION ONE - SNFABN Advanced Beneficiary Notice (ABN) 1. SNFABN CMS-10055: An ABN is to inform a Medicare beneficiary, before he or she receives specified items or services that Medicare may not pay for them under certain circumstances. 2. NEMB-SNF CMS-20014: A NEMB is a type of ABN, but the purpose of a Notice of Exclusion from Medicare Benefits (NEMB) is to inform a Medicare beneficiary, before he or she receives specified items or services that Medicare will not pay for them under any circumstances as the item or service is not a covered benefit. In some instances, issuing a notice for a technical denial (e.g. exhaustion of benefits) is voluntary. 41 OPTION - ONE 42 FH28 - Developed by Polaris Group Page 24 of 73

26 43 OPTION TWO NOTICES OF NON- COVERAGE 44 FH28 - Developed by Polaris Group Page 25 of 73

27 OPTION TWO NOTICES OF NON- COVERAGE 45 Second Page for either Notice Admission or Continued Stay OPTION TWO NOTICES OF NON- COVERAGE 46 FH28 - Developed by Polaris Group Page 26 of 73

28 SNFABN upon Admission Admission to SNF All Medicare beneficiaries should receive a notice if Medicare Part A is not going to pay as best practice. If resident had been in a SNF under another payer source, transferred to hospital, and then readmitted and will not qualify for Medicare Part A, consider issuing notice. Check with your MAC as notice may not be necessary if issued on first admit. If not issued on first admission, then issue for this admission. 47 SNFABN upon Admission Circumstances in which the notice must be issued upon admission: The team determines that the resident does not meet technical requirement (e.g. three consecutive midnights rule). Optional Notice - NEMB-SNF (CMS-20014) or SNF Determination Upon Admission Notice The team determines medical necessity requirements for Part A are not met. SNFABN (CMS-10055) or SNF Determination Upon Admission Notice 48 FH28 - Developed by Polaris Group Page 27 of 73

29 SNFABN upon Admission The team determines the resident qualifies for Part A services, but there is no Medicare-certified bed available. Optional Notice - NEMB-SNF (CMS-20014) or SNF Determination Upon Admission Notice The team determines that the resident qualifies for Part A services, but the resident waives their benefits and consents to placement in a non-certified bed. Optional Notice - NEMB-SNF (CMS-20014) or SNF Determination Upon Admission Notice 49 Continued Stay SNFABN Continued Stay Determination Notices Issue on or before last covered day. If a resident is moving from one SNF to another SNF with a continuation of the Part A stay, no notice of any type is required. No notice is required if transferring to a hospital. The team determines the resident no longer qualifies for skilled Part A services due to medical necessity or custodial care. Notice must be issued on or before last covered day. 50 FH28 - Developed by Polaris Group Page 28 of 73

30 Continued Stay SNFABN Scenario One: The resident will continue in the SNF under a different payer source. Issue SNFABN (CMS-10055) or Continued Stay Determination Notice Scenario Two: The physician discharges the resident to another setting (lower level of care) or home. No financial risk if resident discharged from SNF at same time as discharge off Part A No SNFABN/Notice is required. However, issuing a SNFABN helps protect the SNF if there is risk the resident will not discharge by 11:59 pm on planned day of discharge. 51 Must Continue to Issue Generic Notice/NOMNC When are you required to issue both SNFABN/NOMNC? When a resident is discharged from Part A and remaining in the facility an SNFABN AND a NOMNC will be issued. You can issue both at the same time, and suggest if they want to appeal, to contact the QIO immediately. Exercising Right for a Expedited Review is best for resident and provider. 52 FH28 - Developed by Polaris Group Page 29 of 73

31 53 Exhaustion of Benefits Exhaustion of Benefits No Notice required considered voluntary. Nothing to appeal. Most SNFs prefer to notify resident s that their benefit is about to exhaust. Options: Create own letter Use NEMB-SNF CMS FH28 - Developed by Polaris Group Page 30 of 73

32 Completing SNFABN Notices Complete the SNFABN form (CMS-10055): SNF identifier information should be on form Insert Date of Notice. This date should never be later than last covered day. (Where personal delivery is not possible, include both the date and time you notified the responsible party by telephone and the date you mailed the notice.) Complete Items and/or Service Box: Choose a SNF Denial Paragraph that explains the service being denied Insert effective date(s) - Consider two dates: Last date Medicare pays for care and first date new payer source is liable. Be clear with dates. 55 Completing SNFABN Notices Complete the SNFABN form (CMS-10055): Because Box: Choose a Denial Paragraph that explains the reason why the services do not meet Medical Necessity requirements or are custodial care. Complete Estimated Cost line: Indicate estimated cost for item. If multiple items, list a total cost or a cost per item as desired by resident. Use private pay charges as a guideline. Insert name of other insurance. If no other insurance exists, note none Insert the address, telephone and TTY/TDD phone numbers for your Fiscal Intermediary/MAC Insert Resident s name - Insert Resident s Medicare # 56 FH28 - Developed by Polaris Group Page 31 of 73

33 Sample Denial Statement Medicare covers medically necessary skilled rehabilitation services when needed on a daily basis. The (specify) therapy services provided was/were not reasonable in relation to the expected improvement in your condition. In this case, since you do not need skilled nursing on a daily basis and the therapy services are not considered reasonable and necessary, we believe, your stay is not covered under Medicare FH28 - Developed by Polaris Group Page 32 of 73

34 Completing NEMB Complete the NEMB-SNF (CMS-20014): Insert Date of Notice enter the date on which you gave the NEMB-SNF personally to the resident or to his or her authorized representative. Where personal delivery is not possible, include both the date you notified the resident by telephone and the date you mailed the notice. Complete Medicare will not pay for : indicate items or services, in this case Part A benefits for medical care and room and board. Indicate clearly as to last paid day by Medicare and first day next payer source takes over Check the box that best represents reason for the technical exclusion. 59 Completing NEMB Complete the NEMB-SNF (CMS-20014): Cost line: Indicate estimated cost for item. If multiple items, list a total cost or a cost per item as desired by resident. Use private pay charges for a guideline. Insert name of other insurance. If no other insurance exists, note none. Insert the address, telephone and TTY/TDD phone numbers for your Fiscal Intermediary/MAC Insert Resident s name Insert Resident s Medicare number 60 FH28 - Developed by Polaris Group Page 33 of 73

35 Notices of Determinations SNF Determination Upon Admission SNF Determination of Continued Stay See CMS forms 61 OPTION TWO NOTICES OF NON- COVERAGE 62 FH28 - Developed by Polaris Group Page 34 of 73

36 OPTION TWO NOTICES OF NON- COVERAGE 63 Second Page for either Notice Admission or Continued Stay OPTION TWO NOTICES OF NON- COVERAGE 64 FH28 - Developed by Polaris Group Page 35 of 73

37 Completing Determination Notices SNF Determination on Admission There are two parts of a SNF Denial Letter: SNF Determination on Admission Request for Medicare Intermediary Review Complete page one: SNF Determination on Admission The date is the date the determination was made which is the admit date. Enter resident s name. beginning on date, insert first day without Medicare coverage which is the admit date. 65 Completing Determination Notices SNF Determination on Admission Use appropriate SNF denial paragraph for reason or reason for technical denial. Complete page two: Request for Medicare Intermediary Review Explain billing options Have resident indicate decision Complete C: Insert date of receipt and obtain signature of resident or authorized representative 66 FH28 - Developed by Polaris Group Page 36 of 73

38 Completing Determination Notices SNF Determination on Continued Stay There are two parts of a SNF Denial Letter: SNF Determination on Continued Stay Request for Medicare Intermediary Review Complete page one: SNF Determination on Continued Stay The date is the date the determination was made. Enter resident s name. Medicare last day covered is. and beginning on date, insert first day without Medicare coverage. Indicate last day paid by Medicare and first day they are responsible for the bill for clarity. 67 Completing Determination Notices Complete page one: SNF Determination on Continued Stay (cont.) Use appropriate SNF denial paragraph for reason. Billing will be submitted for admit date through last covered day date. Complete page two: Request for Medicare Intermediary Review Explain billing options Have resident indicate decision Complete C: Insert date of receipt and obtain signature of resident or authorized representative 68 FH28 - Developed by Polaris Group Page 37 of 73

39 Issuing Notices When do we issue the notices How do we issue the notices In person Via phone/ /fax 69 Issuing Notices Issuing in person to beneficiary or authorized representative: Review notice in detail Explain all parts of the form Have beneficiary or authorized representative indicate option and sign and date In margins, note date of receipt indicating receipt of signed copy and make a copy, the original for beneficiary or authorized representative and copy for the SNF 70 FH28 - Developed by Polaris Group Page 38 of 73

40 Issuing Notices Denial Notice issued over the telephone; or mail or secure fax or Review notice in detail over phone Explain to the resident how much the service is estimated to cost if Medicare denies the claim Explain that if Medicare denies the claim, the resident must pay for the services Explain Options Document authorized representative s decision statement on the ABN form 71 Issuing Notices Denial Notice issued over the telephone, mail, secure fax or Document date, time of call, staff name, number called, and person receiving the notice. Include relationship to resident. Document phone number called Mail original and one copy of pages one and two certified mail with return receipt requested. In addition, include a return envelope for return of one signed copy. 72 FH28 - Developed by Polaris Group Page 39 of 73

41 Issuing Notices Other procedures: If refusal to sign, note date, time, and refusal, with second witness and file Make copies of all forms for the financial file Demand bill requested: SNF must process a demand bill Resident is at risk to pay any days after last covered day SNF cannot bill resident until demand bill is processed and decision upheld 73 Medicare Advantage (MA) Notices 74 FH28 - Developed by Polaris Group Page 40 of 73

42 Medicare Advantage (MA) Notices MA Residents have the overall same rights to appeal Appeal to Medicare Advantage (demand bill) Appeal to QIO for an Expedited Review 75 Medicare Advantage Denial Notices MA should ensure a notice is issued when a Part A stay is ending as the resident has a right to appeal. MA may ask SNF to assist with issuing notice Notice of Denial of Medical Coverage: CMS NDMCP Issue on or before last covered service/day Follow procedures outlined by MA Right to appeal to MA program Consider issuing as an addendum outlining resident s risk or a modified SNFABN. 76 FH28 - Developed by Polaris Group Page 41 of 73

43 Medicare Advantage Expedited/NOMNC Notice Expedited Review Notice The SNF has responsibility along with the MA to ensure this notice is properly issued. Issue Notice of Medicare Non-Coverage (NOMNC) CMS Use same form as for Part A/B - effective May 1, 2012 Issue two days before last covered day or service Follow MA procedures 77 Medicare Advantage Expedited/NOMNC Notice Expedited/NOMNC Notice Only issue Detailed Explanation if appeal requested - CMS DENC Use same form as for Part A/B May 1, 2012 Right to appeal to QIO Expedited Review is best choice for resident and SNF Appeal process overall the same as for non- MA residents 78 FH28 - Developed by Polaris Group Page 42 of 73

44 ABN & Expedited/NOMNC Notices for Part B 79 ABN & Expedited/NOMNC Notices for Part B Requirement for ABN & Expedited/NOMNC for Part B Services The provider billing Medicare has primary responsibility to provide notice. Prior to reaching the cap, therapy determines Medicare will not continue to pay as medically reasonable and necessary; but resident wants to continue therapy. Issue ABN CMS R-131 for one or all therapies they are at risk for liability. New form effective 06/17 download from CMS website Issue NOMNC CMS when all therapies are ending. 80 FH28 - Developed by Polaris Group Page 43 of 73

45 81 ABN & Expedited/NOMNC Notices for Part B Example: A resident is receiving one or multiple therapies and therapy determines that ALL services will not continue to meet Medicare criteria for reasonable and necessary service. However, the resident wants to continue to receive therapy; but since Medicare guidelines are not met, the resident would be billed for the services. Issue ABN CMS R-131 form as resident is at financial risk and has the right to a demand bill. Issue an Expedited Review/NOMNC (CMS-10123) The resident has a right to have the medical necessity reviewed by QIO. 82 FH28 - Developed by Polaris Group Page 44 of 73

46 ABN & Expedited/NOMNC Notices for Part B Example: Resident is receiving multiple therapies PT and OT, and then PT ends as team feels care is not medically necessary; and is still under the cap. The resident wants to continue with PT. ABN CMS R-131 Form is required No Expedited Review/NOMNC (CMS ) is required since just a reduction of service; not required until all therapy end. If all services were ending, then issue NOMNC 83 ABN & Expedited/NOMNC Notices for Part B Reaching the cap and qualify for Exception: Example: A resident is receiving PT and will soon reach the Cap. PT is medically necessary beyond the Cap per exception criteria. Therapy will continue under the exception to the Cap as medically necessary. No ABN required (CMS R-131). No Expedited Review/NOMNC (CMS-10123) required. 84 FH28 - Developed by Polaris Group Page 45 of 73

47 ABN & Expedited/NOMNC Notices for Part B Resident has been receiving therapy under the exception policy, they are reaching the cap and all therapy is ending. The resident wants to continue to receive therapy. ABN is required The resident is liable only if ABN is issued. Facility is not planning to bill Medicare. $3,700 threshold issue does not apply since not billing Medicare. Issue NOMNC since the medical necessity could be reviewed. 85 Resident Liability When is resident liable: Medicare covers medically reasonable and necessary therapy services up to $1,980 cap in For services between $1,980 and $3,700, if the conditions meet exception criteria, the assumption is claim will be paid. For services above the $3,700 threshold, a manual review will be done, and the beneficiary is only financially liable if you have issued an ABN because you did not think the services were medically reasonable and necessary but resident wanted therapy. 86 FH28 - Developed by Polaris Group Page 46 of 73

48 87 Completing ABN Form for Part B Issue ABN CMS R-131 Identifying information Body: For therapy; indicate the modality, frequency, and reason for service. For example, physical therapy for 60 minutes, 5 times a week for gait training. Indicate last treatment day Medicare will pay, and first treatment day resident would be liable if receive services. 88 FH28 - Developed by Polaris Group Page 47 of 73

49 Completing ABN Form for Part B Reason Medicare May Not Pay: In this blank, notifier must explain, in beneficiary friendly language, why they believe the items or services described in Blank (D) may not be covered by Medicare. Three commonly used reasons for non-coverage are: Medicare will not pay for this service because it does not meet medical necessity requirements for your condition Medicare does not pay for this test for your condition Medicare does not pay for this test as often as this (denied as too frequent) Medicare does not pay for experimental or research use tests 89 Completing ABN Form for Part B For therapy: Estimate the total number of units for a daily or weekly total charge. Use the dollar amount that will be charged to the resident for each unit for the service. This is not the same as the fee screen. Explain and select Options Signature and Dates Follow procedures for SNF-ABN related to proper notifications, documentation and maintenance of records May bill pending review 90 FH28 - Developed by Polaris Group Page 48 of 73

50 Expedited/NOMNC Notices for Part B Timing the notice must be issued no later than next to last visit before coverage ends If therapy is planned for Tuesday and Thursday, and Tuesday is last covered treatment day, the notice must be issued no later than the preceding Thursday. Complete NOMNC (CMS-10123) in same manner as for Part A services Only complete Detailed Notice (CMS-10124) if an appeal is made 91 SCENARIOS 1. Resident admitted after a two day hospital stay; the resident has Medicare coverage. Forms: NEMB-SNF (CMS ) optional 2. Resident has been Part A for skilled therapy and nursing observation and assessment for 40 days. All therapy is being discontinued and the resident is no longer skilled; and the end of Part A stay is coordinated with discharge home. Forms: NOMNC CMS Same scenario as for #2, but resident will remain in facility under a different payer source. Forms: SNFABN CMS and NOMNC CMS FH28 - Developed by Polaris Group Page 49 of 73

51 SCENARIOS Resident is receiving Part B therapy, and the resident continues to need therapy, but is about to reach the therapy cap. The plan is to continue therapy using the automatic exception process. Forms: No ABN required, no NOMNC is required Same as above; about to reach the cap with no exception process but resident wants to continue therapy. Forms: ABN required CMS R-131 and NOMNC is required 93 Summary Review current procedures for issuing notices Expedited Review Notices Determination Notices/ABN Ensure communication with MDS Nurse regarding Effective dates during weekly Medicare Meetings or Daily Stand-up meetings. Ensure procedures in place to respond quickly to notice of a QIO appeal to process records to QIO that day. Review procedures if needed with any MA programs as they are required to ensure notices are provided as required. 94 FH28 - Developed by Polaris Group Page 50 of 73

52 SNF NOTICES QUICK REFERENCE Situation PART A 1 On Admission to SNF: Beneficiary has not had 3-day hospital stay or no benefit days left 2 On Admission to SNF: Beneficiary had 3-day hospital stay and has MD orders for care, but does not meet requirements of a daily skilled service. 3 On Admission to SNF No Medicare certified bed is available 4 On Admission to SNF Resident qualifies for Part A, but waives benefit. 5 Part A Stay ends because: Beneficiary is discharged to acute hospital, psych or rehab hosp 6 Part A Stay ends because: Beneficiary leaves AMA 7 Part A Stay ends at your facility because: Beneficiary is transferred to another SNF, will continue to be covered under Part A. 8 Part A Stay will end because: Beneficiary no longer requires daily skilled services but will remain in the SNF. 9 Part A Stay will end because: Provider determines that beneficiary no longer requires daily skilled service, and is discharged home. 10 Benefit Days Exhausted Beneficiary has been in facility for Part A stay and still requires daily, skilled care, however has exhausted 100 days benefit. 11 Medical Advantage Enrollee The Health Plan is responsible to ensure a Denial Notice is given per the above scenarios, and the SNF is required to give the Exp Review per above scenarios. 12 Resident signs over benefits from SNF Part A to Hospice Part A; remaining in facility but changing to Hospice payment. ABN or Notice of Non-Coverage liability notice Must be issued before receiving non-covered services. Form should include two dates: Last day Medicare will pay and first day beneficiary is liable. NEMB-SNF (CMS-20014) or SNF Determination on Admission (optional) SNFABN (CMS-10055) or SNF Determination on Admission NEMB-SNF (CMS-20014) or SNF Determination on Admission (optional) NEMB-SNF (CMS-20014) or SNF Determination on Admission (optional) No Notice Required No Notice Required No Notice Required SNFABN (CMS-10055) or SNF Determination on Continued Stay No Notice Required (Best practice is to issue SNFABN if there is a risk the resident would stay past 11:59 pm of day of discharge). NEMB-SNF (CMS-20014) (voluntary notice - optional) Health Plan is required to provide the Notice (CMS-10003) No Notice Required Expedited Determination/Generic Notice (QIO)- Fast Track Issue 2 days before Effective date. Effective Date is last paid day No Expedited Determination/Generic Notice required No Expedited Determination/Generic Notice required No Expedited Determination/Generic Notice required No Expedited Determination/Generic Notice required No Expedited Determination/Generic Notice required No Expedited Determination/Generic Notice required No Expedited Determination/Generic Notice required Expedited Determination/Generic Notice required (CMS-10123) Expedited Determination/Generic Notice required (CMS-10123) No Expedited Determination/Generic Notice required when benefits exhaust Expedited Determination/Generic Notice required (CMS-10123) No Expedited Determination/Generic Notice required FH28 - Developed by Polaris Group Page 51 of 73

53 SNF NOTICES QUICK REFERENCE Situation PART B 1 Part B Therapy determines that the services are no longer medically reasonable and necessary and Medicare will no longer continue to pay for any therapy services. The resident does not want to receive any more therapy. 2 Part B Any time (before or after reaching the cap) therapy determines that the services are not medically reasonable and necessary and Medicare will not pay for therapy services by one or all disciplines but resident wants to continue to receive therapy, this would make the resident liable for payment for therapy services by one or more disciplines. With any risk for liability for payment, the resident must receive an ABN. An Expedited Review is only required when all therapies are ending. 3 Part B SNF items/services that are not medically reasonable and necessary or never covered under Medicare are expected to be denied under Medicare Part B. For example: Medicare pays for 2 urinary catheters a month but the resident requests the urinary catheter be changed weekly. Medicare Part B never pays for the additional 2 urinary catheters that are not medically reasonable and necessary. ABN or Notice of Non-Coverage liability notice Issue no later than day before last covered treatment/day No ABN (CMS R-131) is required ABN (CMS R-131) is required for each/all disciplines that will continue after last covered service. Mandatory - ABN (CMS R-131) is required. Resident will be responsible for denied charges. Expedited Determination/Generic Notice (QIO) - Fast Track Issue on the second to last covered treatment/day. Mandatory When all services are ending-expedited Determination/Generic Notice (CMS ) Mandatory When all services are ending - Expedited Determination/Generic Notice (CMS ) No Expedited Determination/Generic Notice (CMS-10123) SNFABN = CMS NEMB-SNF = CMS ABN = CMS-R-131 Updated Generic/Expedited Review Notice (Notice of Medicare Provider Non-Coverage) = CMS (NOMNC)** **Member numbers should not be member s Medicare number Detailed Explanation Notice = CMS (DENC) (only issued if an appeal is requested of the QIO) Medicare Advantage/Health Plan Notice of Non-coverage/Expedited QIO review = CMS (NOMNC) Medicare Advantage/Health Plan Detailed Explanation of Non-Coverage = CMS (DENC) (issue if an appeal is requested of QIO) Medicare Advantage/Health Plan Notice of Denial of Medicare Coverage CMS-10003NDMCP; Issued by Health Plan FH28 - Developed by Polaris Group Page 52 of 73

54 EXAMPLE OF NOTIFICATION AND APPEAL PROCESS WHEN GENERIC NOTICE - NOMNC IS TIMELY FOR PART A: June 2 June 3 June 4 June 5 June 6 NOMNC Delivered Bob receives a NOMNC indicating that his coverage is ending June 4th. Bob must request an expedited determination by noon today. The QIO must notify the SNF of Bob s request for an expedited determination. The SNF must deliver the DENC to Bob by COB today. The SNF must provide relevant medical records to the QIO by COB today. NOMNC Effective Date This is the last day of coverage, as stated on the NOMNC. The beneficiary has no liability for this day as this is the last day of coverage in the SNF. If Bob made his request on June 2nd: The QIO makes its decision and notifies Bob and the SNF by COB. If QIO decision is unfavorable: Beginning today Bob is liable for his stay if he does not leave the SNF. If Bob made his request on June 3rd: The QIO makes its decision and notifies Bob and the SNF by COB. FH28 - Developed by Polaris Group Page 53 of 73

55 SAMPLE {Insert provider contact information here} Notice of Medicare Non-Coverage Patient name: John Smith Patient number: XXXXXX The Effective Date Coverage of Your Current Medicare Part A Services Will End: July 9 th 20XX Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current {insert type} services after the effective date indicated above. You may have to pay for any services you receive after the above date. Clearly state when liability could start. Your Right to Appeal This Decision You have the right to an immediate, independent medical review (appeal) of the decision to end Medicare coverage of these services. Your services will continue during the appeal. If you choose to appeal, the independent reviewer will ask for your opinion. The reviewer also will look at your medical records and/or other relevant information. You do not have to prepare anything in writing, but you have the right to do so if you wish. If you choose to appeal, you and the independent reviewer will each receive a copy of the detailed explanation about why your coverage for services should not continue. You will receive this detailed notice only after you request an appeal. If you choose to appeal, and the independent reviewer agrees services should no longer be covered after the effective date indicated above; o Neither Medicare nor your plan will pay for these services after that date. If you stop services no later than the effective date indicated above, you will avoid financial liability. How to Ask For an Immediate Appeal You must make your request to your Quality Improvement Organization (also known as a QIO). A QIO is the independent reviewer authorized by Medicare to review the decision to end these services. Your request for an immediate appeal should be made as soon as possible, but no later than noon of the day before the effective date indicated above. The QIO will notify you of its decision as soon as possible, generally no later than two days after the effective date of this notice if you are in Original Medicare. If you are in a Medicare health plan, the QIO generally will notify you of its decision by the effective date of this notice. Call your QIO at: INSERT PHONE NUMBER to appeal, or if you have questions. See page 2 of this notice for more information. FH28 - Developed by Polaris Group Page 54 of 73

56 Form CMS NOMNC (Approved 12/31/2011) OMB approval If You Miss The Deadline to Request An Immediate Appeal, You May Have Other Appeal Rights: If you have Original Medicare: Call the QIO listed on page 1. If you belong to a Medicare health plan: Call your plan at the number given below. Plan contact information Additional Information (Optional): Medicare covers medically necessary skilled care needed on a daily basis. Your care is only support care and does not meet requirements of a daily skilled service. Annotation Required if reviewing over phone or with a unnamed (not legal) representative in person: Name of staff person, date, time, number called if over phone, person spoke to, and write Reviewed last covered day, first day liability would start, appeal rights and timing, and provided the QIO number on this form. Please sign below to indicate you received and understood this notice. I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO. Signature of Patient or Representative Date Form CMS NOMNC (Approved 12/31/2011) OMB approval FH28 - Developed by Polaris Group Page 55 of 73

57 Detailed Notice for QIO: Sample ONE We have reviewed your case and decided that Medicare coverage of your current {insert type} services should end. The facts used to make this decision: Resident admitted on May 1, 2012 post fracture hip with a functional decline. Resident required therapy for gait training, balance, and bed mobility related to functional decline (insert PT/OT/ST ORDERS). Mr Smith also had new meds for hypertension and weight loss so VS were monitored and ADL support provided. Resident health status has stabilized over the last week and resident has reached prior level of function before fracture. Discharge plan is to go back to assisted living apartment. Detailed explanation of why your current services are no longer covered, and the specific Medicare coverage rules and policy used to make this decision: This resident has met therapy goals for discharge, therapy is being discontinued as therapy is not medically indicated 5 days a week. No new medications or changes in medical status are likely to occur. Plan policy, provision, or rationale used in making the decision (health plans only): Medicare only covers Part A when daily skilled services are medically indicated and provided. In this case, there is no need for skilled nursing on a daily basis and the therapy services are not considered reasonable and necessary for current status. Provided by Polaris Group FH28 - Developed by Polaris Group Page 56 of 73

58 Resident s Name John Smith Medicare (HICN) XXX SNF: Address: Phone #: ( ) TTY/TDD: ( ) Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) Date of Notice: July 1, 20XX NOTE: You need to make a choice about receiving these health care items or services. It is not Medicare's opinion, but our opinion, that Medicare will not pay for the item(s) or service(s) described below. Medicare does not pay for all of your health care costs. Medicare only pays for covered items and services when Medicare rules are met. The fact that Medicare may not pay for a particular item or service does not mean that you should not receive it. There may be a good reason to receive it. Right now, in your case, Medicare probably will not pay for Items or Services: Part A Medicare Coverage: the last day Medicare Part A will pay is July 3, 20XX, and the first day other coverage takes over is July 4, 20XX. Because: Medicare covers medically necessary skilled care needed on a daily basis. You only need support care. This does not require the skills of a licensed nurse or professional to perform the service or to manage your care, we believe your stay will not continue to be covered under Medicare. The purpose of this form is to help you make an informed choice about whether or not you want to receive these items or services, knowing that you might have to pay for them yourself. Before you make a decision about your options, you should read this entire notice carefully. Ask us to explain, if you don t understand why Medicare probably won t pay. Ask us how much these items or services will cost you (Estimated Cost: $_OO ), in case you have to pay for them yourself or through other insurance you may have. Your other insurance is: Medicaid If in 90 days you have not gotten a decision on your claim, contact the Medicare contractor at: Address: or at: Telephone: TTY/TDD:. If you receive these items or services, we will submit your claim for them to Medicare. PLEASE CHOOSE ONE OPTION. CHECK ONE BOX. DATE & SIGN THIS NOTICE. Option 1. YES. I want to receive these items or services. I understand that Medicare will not decide whether to pay unless I receive these items or services. I understand you will notify me when my claim is submitted and that you will not bill me for these items or services until Medicare makes its decision. If Medicare denies payment, I agree to be personally and fully responsible for payment. That is, I will pay personally, either out of pocket or through any other insurance that I have. I understand that I can appeal Medicare s decision. XX Option 2. NO. I will not receive these items or services. I understand that you will not be able to submit a claim to Medicare and that I will not be able to appeal your opinion that Medicare won t pay. I understand that, in the case of any physician-ordered items or services, should notify my doctor who ordered them that I did not receive them. Resident s Name: Medicare # (HICN): Date Signature of the resident or of the authorized representative Form No. CMS Customized FH28 - Developed by Polaris Group Page 57 of 73