Provider-Issued Beneficiary Forms

CMS' Beneficiary Notices Initiative (BNI) offers financial liability protections and appeal rights to Medicare beneficiaries and providers.

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View the issuance rationale and timeliness standards for the common beneficiary forms.

Prior to Admission

Form Name Medicare Part Issuance Reason Timeliness
Medicare Outpatient Observation Notice (MOON) Part A (includes MA Plans)
  • Informs a beneficiary that he/she is an outpatient receiving observation services and is not an inpatient of a hospital or Critical Access Hospital (CAH)
  • Issue to beneficiary when observation services are greater than 24 hours
  • Form must be delivered no later than 36 hours after observation services as outpatient begin
  • Clock begins when observation services are first furnished to beneficiary, as indicated in medical record
Hospital-Issued Notice of Noncoverage (HINN) 1 Part A
  • Issued in preadmission situations
  • Beneficiary is liable, if admitted, for customary charges for all services furnished during the stay, except for services for which he/she is eligible to receive payment under Part B
  • Applies to direct admissions to swing beds
Preadmission
  • Beneficiary is liable, if admitted, for customary charges for all services furnished during the stay, except for services for which he/she is eligible to receive payment under Part B
Admission
  • If admission notice is issued at 3 p.m. or earlier on day of admission, beneficiary is liable for customary charges for all services furnished after receipt of notice, except for services for which beneficiary is eligible to receive payment under Part B
  • If admission notice is issued after 3 p.m. on day of admission, beneficiary is liable for customary charges for all services furnished on day following day of receipt of notice, except for services for which beneficiary is eligible to receive payment under Part B

 

After Admission

Form Name Medicare Part Issuance Reason Timeliness
Important Message from Medicare (IM) Part A (includes MA Plans)
  • Informs hospitalized inpatient beneficiary of his/her hospital discharge appeal rights
  • Explains how beneficiary may request expedited review of discharge decision by Quality Improvement Organization (QIO)
  • Must be delivered no later than two calendar days after admission
  • IM, or copy of IM, must also be provided to beneficiary within two calendar days of day of discharge
    • If delivery of initial IM occurs more than two days before discharge, hospitals will deliver a follow-up copy of signed notice to beneficiary as soon as possible prior to discharge, but no more than two days before
  • Includes psychiatric admissions
HINN 10 (also known as the Hospital Requested Review [HRR]) Part A (includes MA Plans)
  • Issued when a hospital determines that a beneficiary no longer needs inpatient care, but is unable to obtain agreement of physician, hospital may request a QIO review. Hospitals must notify beneficiary that the review has been requested
  • This should never be delivered to beneficiary

 

Prior to Discharge

Form Name Medicare Part Issuance Reason Timeliness
HINN 12 Part A
  • Used in association with Hospital Discharge Appeal Notice to inform beneficiary of his/her potential liability for noncovered continued stay
  • Hospitals must only give notice when planning to charge beneficiary
  • Hospitals are not required to issue a HINN when they do not plan to bill beneficiary or his/her representative
Detailed Notice of Discharge (DND) Part A (includes MA Plans)
  • Informs beneficiary of QIO determination of appropriateness of beneficiary's discharge when beneficiary requests QIO review
  • Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) physician will review beneficiary's medical record to determine if discharge is or isn't appropriate
  • Hospitals must deliver DND, as soon as possible, but no later than noon on day after QIO notification
  • Beneficiary signature not required

 

Noncovered/Services Ending

Form Name Medicare Part Issuance Reason Timeliness
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
  • 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
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
  • 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
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
  • 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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Last Updated Tue, 04 Feb 2020 15:28:56 +0000