SNF Demand Review Interim Findings - JE Part A

An advanced beneficiary notice (ABN) is a written notice of Medicare denial of payment and must contain sufficient information to enable the beneficiary or authorized representative to understand the basis for the denial. In order for a SNF to transfer liability to a beneficiary for items or services paid under Medicare Part A, the SNF must issue a SNF ABN for an item or service that may not be paid for by Medicare due to not being medically reasonable and necessary or custodial care. Such notice must be given to the beneficiary timely, before he or she receives specified items or services that otherwise might be paid for so that the beneficiary has time to make other arrangements.

The SNFABN provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. For additional SNF ABN information, refer to the Medicare Claims Processing Manual (MCPM) Chapter 30 section 70.

Please refer to the SNFABN and instructions which are located on the CMS FFS SNF ABN webpage. The SNFABN has the following 5 sections for completion: Header, Body, Option Boxes, Additional Information, Signature and Date. Failure to use this notice or significant alterations of the SNFABN could result in the notice being invalidated and/or the SNF being held liable for the care in question.

The Header must include SNF information including SNF name, address, and phone number, at a minimum. The header must also include the patient's name. Patient identification number is optional.

The Body must include the "beginning on…," date which the beneficiary may be responsible for payment. The Care, Reason Medicare May Not Pay, and Estimated Cost sections must also be completed in the Body.

In the Option Boxes section, there are three options with corresponding checkboxes. The beneficiary must check only one option box. If the beneficiary is physically unable to make a selection, the SNF may enter the beneficiary's selection at his/her request and indicate on the notice that this was done for the beneficiary.  Otherwise, SNFs are not permitted to select or pre-select an option for the beneficiary as this invalidates the notice.

SNFs may use the Additional Information section to clarify and/or provide additional information they think might be helpful to the beneficiary.

The Signature and Date section must be signed by the beneficiary or their authorized representative to acknowledge s/he understood the notice. The SNF may fill in the date if the beneficiary requires assistance. This date should reflect the date that the SNF gave the notice to the beneficiary in-person, or when appropriate, the date contact was made with the beneficiary's authorized representative by phone. If an authorized representative signs for the beneficiary, write "(rep)" or "(representative)" next to the signature. If the beneficiary refuses to choose an option and/or refuses to sign the SNFABN when required, the SNF should annotate the original copy of the SNFABN indicating the refusal to sign and may list a witness to the refusal.

In order for a Beneficiary to receive coverage in a skilled nursing facility (SNF), the following criteria must be met:

• The beneficiary must be entitled to receive Medicare Part A
• There must be a medically necessary 3-day qualifying hospital stay
• Transfer or admission to the SNF must occur within 30 days at a skilled level of care
• Benefit days must be available to the beneficiary
• The patient requires skilled nursing services or skilled rehabilitation services, i.e.:
  • Services must be performed by or under the supervision of professional or technical personnel (see section 30.2 - 30.4)
  • Services must be ordered by a physician and rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services.
• The patient requires these skilled services on a daily basis (see section 30.6) and as a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. (see section 30.7.)
• The services must be reasonable and necessary for the treatment of a patient's illness or injury, i.e.:
  • Being consistent with the nature and severity of the individual's illness or injury, the individual's particular medical needs, and accepted standards of medical practice.
  • The services must also be reasonable in terms of duration and quantity.
• The patient must be admitted to a SNF within 30-days of discharge from a hospital and require skilled care. (See exception to this criteria)

If any one of these factors is not met, a stay in a SNF, even though it might include the delivery of some skilled services, is not covered. For example, payment for a SNF level of care could not be made if a patient needs an intermittent rather than daily skilled service.

Skilled care in a SNF is covered if all of the following factors are met:

• An inpatient stay is required.
• A physician's order is in place and the patient requires skilled nursing services or skilled rehabilitation services on a daily basis.
• Services must be performed by or under the supervision of skilled nursing or rehabilitation professionals.
• Services need to be reasonable and necessary for the treatment of the patient's illness or injury.

It is the responsibility of Medicare providers to submit all documentation requested on the additional documentation requests (ADR) within the allotted time frame. Noridian allows 45 calendar days for the medical records to be received per the ADR request for prepayment reviews. On day 46, if the medical records have not been received, the claim will be denied provider liable with reason code 56900. If there is no documentation to complete the medical review (MR), services billed on the claim cannot be supported.

A redetermination request should be submitted to Noridian within 120 days from the date of the 56900 denial. Contractors shall reopen the claim for review as long as all conditions are met. The determination made on the reopening claim has the potential to reverse non-covered dollars.

For additional information, refer to Internet-only Manual Pub 100-08, Chapter 3, Section 3.2.3.8, 42 CFR 424.5(a)(6), and Social Security Act sections 1815(a), 1833(e) and 1862(a)(1)(A).