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SNF Notices of Non-Coverage Cheat Sheet by

Table of when & which ABNs are required
nursing     snf     healthcare     notices     non-coverage     abn

Advance Benefi­ciary Notice of Noncov­erage (ABN)

If you have Original Medicare and your health care provider, or supplier thinks Medicare probably (or certainly) won't pay for items or services, they may give you a written notice called an "­Advance Benefi­ciary Notice of Noncov­era­ge" (ABN). However, an ABN isn't required for items or services that Medicare never covers.

Other Types of ABNs

"­Skilled Nursing Facility Advance Benefi­ciary Notice of Non-Co­ver­age­" (SNFABN): A skilled nursing facility (SNF) will issue you a SNFABN if there's a reason to believe that Part A may not cover or continue to cover your care or stay because it isn't reasonable or necessary, or is considered custodial care. This written notice gives you choices similar to the ABN. The SNFABN tells you the date when Medicare will likely no longer pay for your services. If you choose to get the services that may not be covered by Medicare, you don't have to pay for these services until a claim is submitted and Medicare officially denies payment. However, while the claim is processed, you have to continue paying costs that you would normally have to pay, like the daily coinsu­rance and costs for services and supplies Medicare generally doesn't cover.

SNF Notices of Non-Co­verage

Scen­ario
What Notices to Give
Requ­ired
When to Give Notice
Benefi­ciary drops to a non-sk­illed level of care
• Benefits have not exhausted
• Benefi­ciary remains in the facility (Medicare certified bed OR non-Me­dicare certified bed)
SNFABN (CMS 10055) or SNF Denial Letter AND Generic Expedited Determ­ination (CMS 10123)
Yes
No later than 2 days before covered services end
Services constitute custodial care
SNFABN (CMS 10055) or SNF Denial Letter OR Revised ABN (CMS-R­-131)
Yes
Prior to providing services
SNF feels Part A services are not medically reasonable and necessary
SNFABN (CMS 10055) or SNF Denial Letter OR Revised ABN (CMS-R­-131)
Yes
Prior to providing services
Benefits have exhausted
SNF NEMB (CMS 20014)
No
Prior to benefits exhausting
• No Qualifying Hospital Stay (QHS)
• Did not meet 30 day transfer requir­ement
SNF NEMB (CMS 20014)
No
Prior to providing services
SNF feels Part B services are not medically reasonable and necessary
Revised ABN (CMS-R­-131)
Yes
Prior to providing services
Benefi­ciary chooses to terminate services, not the SNF
None
N/A
N/A
Benefi­ciary drops to a non-sk­illed level of care
• Benefits have not exhausted
• Benefi­ciary goes home
Generic Expedited Determ­ination (CMS 10123)
Yes
No later than 2 days before covered services end
All Part B services on a plan of care are ending
Generic Expedited Determ­ination (CMS 10123)
Yes
No later than 2 days before covered services end
Benefi­ciary requests expedited review from the QIO
Detailed Expedited Determ­ination (CMS 10124)
Yes
As soon as notified benefi­ciary requested QIO review

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