Centers of Medicare Medicaid Services (CMS) has revised the Skilled Nursing Facility (SNF) Notice of Non-coverage (SNF ABN), form CMS-10055. This new form will be mandatory for use effective May 2018. However, the new form may be used prior to this date. Facilities should insure that they are using the most recent forms for ABN 10055 (used for Part A residents) as well as ABN form R-131 (for Part B residents).
The correct form may be identified by observing the form number at the bottom of the page. Form 10055 should have “2018” enclosed in parentheses next to the form number. ABN form R-131 should have “Exp. 03/2020” enclosed in parentheses next to the form number.
In addition to revision of the ABN form, there has also been a change to processes where the Notice of Exclusion of Medicare Benefits (NEMB form 20014) will no longer be used. Instead, the new ABN from (10055) will be used in its place. Essentially, all other forms (e.g. NOMNC form 10123, etc.) will remain in use.
As a review, we might consider the following scenarios:
Scenario # 1: The resident is covered under traditional Part A coverage for therapy services for a period of 40 days with benefit days remaining. The facility has determined that the resident no longer requires skilled services and the resident is to be discharged home.
Form(s) to be given:
NOMNC (10123) – Notifies beneficiary of ending coverage.
Scenario # 2: The resident is covered under traditional Part A coverage for therapy services for a period of 40 days with benefit days remaining. The facility has determined that the resident no longer requires skilled services and the resident will remain in the facility.
Form(s) to be given:
NOMNC (10123) – Notifies beneficiary of ending coverage.
SNF ABN (10055) – Notifies beneficiary of financial liability once Medicare coverage ends.
Scenario # 3: Resident exhausts traditional Part A benefits while receiving a skilled level of care. The resident will remain in the facility.
Form(s) to be given: No notices required. The facility may voluntarily issue the SNF ABN (10055) to notify the beneficiary of exhaustion of Medicare benefits or another form of the facility’s choosing.
Scenario # 4: A referral is received from the hospital where a resident with traditional Part A coverage only had a two day hospital stay.
Form(s) to be given: No notices required. Technical denial is not a level of care decision. The facility may voluntarily issue the SNF ABN (10055) or a notice of their choosing.
Scenario # 5: The resident is receiving PT and OT services under Medicare Part B. Both disciplines discontinue services. No further therapy is requested.
Form(s) to be given:
NOMNC (10123) – To notify termination of Part B services. No additional therapy services are requested so no ABN (R-131) is necessary.
Scenario # 6: The resident is receiving PT and OT under Medicare Part B. OT discontinues services and the resident will continue with PT. There is no request for further OT services.
Form(s) to be given: No notice is required. The NOMNC (10123) would only be issued once all therapy disciplines discontinue services.
Scenario # 7: The facility has a Medicare conference with the resident and makes a determination that the resident would benefit from additional therapy. The resident decides to go home tomorrow.
Form(s) to be given: No notices required. Resident ended their own coverage.
Scenario # 8: The resident is receiving PT under Medicare Part B coverage. PT discontinues services (“rehab to potential”). The resident and family are requesting PT services to continue.
Form(s) to be given:
NOMNC (10123) – Notification of ending services.
ABN (R-131) – Notification of potential financial liability for additional therapy services.
It is important that facilities review these requirements to assure that they are prepared to comply. For additional information related to letters of non-coverage contact Nathan J. Shaw, RN, BSN, MBA, LHRM, RAC-CT, Vice President of Clinical Reimbursement & Analytics at [email protected] or Robin A. Bleier, RN, LHRM, CLC, President at [email protected] of RB Health Partners, Inc.
By Nathan J. Shaw, RN, BSN, MBA, LHRM, RAC-CT