Advance Beneficiary Notice of Noncoverage (ABN) |
Part A and Part B (not applicable to MA Plans) |
- Informs beneficiaries, in advance, when believing that items or services will likely be denied either as not reasonable and necessary or as constituting custodial care
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- ABN must be delivered far enough in advance that beneficiary or his/her representative has time to consider the options and make an informed choice
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Skilled Nursing Facility (SNF) ABN |
Part A (Form CMS-10055) and Part B (Form CMS-R-131) |
- Issued to beneficiary prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is:
- not medically reasonable and necessary; or
- considered custodial
- Does not apply to swing beds
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- SNF ABN must be delivered far enough in advance that beneficiary or his/her representative has time to consider the options and make an informed choice
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HINN 11 |
Part A |
- Noncovered items or services provided during an otherwise covered stay
- Only used for items or services when there is published Medicare coverage policy
- Inpatient stay must be covered
- If stay was or had become noncovered, other notification requirements would apply (for example, HINN 1)
- Item or service must not be bundled into or integral to payment or treatment for diagnoses/reasons justifying covered inpatient stay
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- Deliver prior to admission, at admission, or at any point during an inpatient stay if hospital determines that items or services beneficiary is receiving, or is about to receive, are not covered
- Immediately effective if understood and signed by beneficiary
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Notice of Medicare Non-Coverage (NOMNC) |
Part A |
- Informs beneficiaries of discharge when Medicare covered services are ending
- Explains how beneficiary may request expedited review of discharge decision by BFCC-QIO
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- Issued at least two days before covered services end or
- Second to last day if care is not provided daily
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Detailed Explanation of Non-Coverage (DENC) |
Part A |
- Given only if a beneficiary requests an expedited BFCC-QIO determination
- Explains the reasons for the end of covered services
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- No later than the close of business of the day of BFCC-QIO notification
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