The new survey process for nursing homes went into effect November 28, 2017. The surveyors will be conducting a Beneficiary Protection Notices Review. The survey team coordinator (TC) will make offsite unit assignments and mandatory facility task assignments for the surveyors. There are nine mandatory facility tasks which include the Beneficiary Protection Notification Review.
The objective of the Beneficiary Protection Notices Review is to determine if the facility issued the Notice of Medicare Non-Coverage as required under 42 CFR Part 405.1200-1204 and §1879(a)(1) of the Social Security Act. It is intended to evaluate a nursing home’s compliance with the requirements to notify Original (Fee-For-Service) Medicare beneficiaries when the provider determines that the beneficiary no longer meets the skilled care requirement. This review confirms that residents receive timely and specific notification when a facility determines that a resident no longer qualifies for Medicare Part A skilled services when the resident has not used all the Medicare benefit days for that episode.
Medicare beneficiaries have specific rights and protections related to financial liability and the right to appeal a denial of Medicare services under the Fee for Service (Original) Medicare Program. These financial liability and appeal rights and protections are communicated to beneficiaries through notices given by providers. The review will be completed on residents who received Medicare Part A services only.
During the entrance conference, the surveyor will ask for a list of Medicare beneficiaries who were discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months prior to the survey. The surveyor will eliminate those residents that had Medicare Part B only, in addition to those that have expired or discharged to another skilled nursing facility (SNF). From the list provided, three random residents will be selected for review. Typically, the surveyor will select one resident who went home and two who remained in the facility. For each of the three residents selected, the surveyor will provide the facility with a Beneficiary Notification Checklist that the provider must complete and return to the survey team. If it is determined that appropriate notices were not given, the surveyor will cite F582 Medicaid/Medicare Coverage/Liability Notice 483.10(g)(17)(18)(i)-(v).
The two forms of notification that will be evaluated in the review, according to the clinical pathway, are:
- Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN)—Form CMS-10055
- Notice of Medicare Non-Coverage–Form CMS 10123-NOMNC, also referred to as a “generic notice”
However, when CMS released the SNF Beneficiary Protection Notification Review pathway, the date on the bottom of the pathway was 2/2017. On this version of the pathway, Question #1 asked, “Was a SNF ABN or one of the five denial letters provided to the resident?” The Centers for Medicare and Medicaid Services (CMS) released an updated pathway with a revision date of 11/2017, along with the updated Appendix PP. Question #1 on the 11/2017 pathway asked, “Was a SNF ABN provided to the resident?” The wording of the five denial letters was removed on the updated pathway, except in the table. Due to the confusion, LW Consulting, Inc. reached out to CMS and the Payment Policy Group. We were informed that both departments attempt to sync the regulations that affect both entities, and they both have deadlines to make sure policies are completed timely. Since then, the Payment Policy Group has designed a new SNF ABN form that takes all previous forms and combines them into one to decrease the confusion of having the five denial letters, ABN and NEMB. In the updated Appendix PP, the Beneficiary Protection Notification Review and the updated clinical pathway were released with the notion that the newly revised SNF ABN was approved and ready for use, which was not the case. The surveyors who were instructed to follow the Appendix PP regulations were to be sent a memorandum on Friday, December 8, 2017 informing them that the new SNF ABN had not been approved and to allow the denial letters to be an appropriate notice of non-coverage until the new SNF ABN form was approved and released.
At this time, the following forms are still active to be used for Medicare Part A Notice of Non-Coverage:
- SNFABN
- Five Denial Letters
- The optional Notice of Exclusions of from Medicare Benefits (NEMB) for Medicare Part A
Any information on updates or changes to the SNFABN form will be published to the Beneficiaries Notices Initiative website at the following link: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html?redirect=/BNI/.
Beneficiary Liability Protection Notice Scenarios for Surveyors
The Beneficiary Liability Protection Notice Scenarios for Surveyors is part of the SNF Beneficiary Protection Notification Review pathway. The chart helps to identify scenarios and which ABN, or ABNs are required and when.
The Beneficiary Liability Protection Notice Scenarios for Surveyors
SNF Advance Beneficiary Notice of Non-Coverage (SNFABN)
The SNF Advanced Beneficiary Notice of Non-Coverage (SNFABN), CMS-10055, is not to be confused with the Advanced Beneficiary Notice of Non-Coverage (ABN), CMS R-131. The SNFABN is used for Medicare Part A services and the ABN is used for Medicare Part B services.
According to the regulations for the Notice of Non-Coverage, a provider must issue advance written notice to Medicare enrollees before termination of services in a Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF). If an enrollee files an appeal, then the plan must deliver a detailed explanation of why services should end.
The two notices used for this purpose are:
- Notice of Medicare Non-Coverage (NOMNC) Form CMS-10123-NOMNC
- Detailed Explanation of Non-Coverage (DENC) Form CMS-10124-DENC
Notice of Medicare Non-Coverage (NOMNC) CMS-10123
A completed copy of the Notice of Medicare Non-Coverage (NOMNC) must be provided to beneficiaries/enrollees receiving covered skilled nursing services two calendar days before Medicare covered services end or the second to last day of service, if care is not being provided daily. It must be delivered even if the beneficiary agrees with the termination of services. The delivery of the NOMNC is the provider’s responsibility.
The NOMNC must be signed and dated to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed.
A paper copy of the NOMNC must be provided to the beneficiary with the required beneficiary-specific information inserted at the time of notice delivery.
Notice Delivery to Representatives
CMS requires that notification of changes in coverage for an institutionalized beneficiary/enrollee who is not competent be made to a representative. Notification to the representative may be problematic because that person may not be available in person to acknowledge receipt of the required notification. Providers are required to develop procedures to use when the beneficiary/enrollee is incapable or incompetent, and the provider cannot obtain the signature of the enrollee’s representative through direct personal contact. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should call the representative to advise him or her when the enrollee’s services are no longer covered.
The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. When direct phone contact cannot be made, a notice should be sent to the representative by certified mail, return receipt requested. The date that someone at the representative’s address signs (or refuses to sign) the receipt is the date of receipt. A dated copy of the notice should be placed in the enrollee’s medical file. When notices are returned by the post office with no indication of a refusal date, then the enrollee’s liability starts on the second working day after the provider’s mailing date.
When a NOMNC is Not Required
An NOMNC is not required when:
- Beneficiaries have never received Medicare covered care in one of the covered settings
- Services are being reduced (Therapy services – one discipline is discontinued)
- Beneficiaries exhaust their benefits
- Beneficiaries end benefits on their own initiative
- Beneficiaries transfers to another nursing home
Alterations to the NOMNC
The NOMNC must remain two pages. The notice can be two sides of one page or one side of two separate pages, but must not be condensed to one page. Providers may include their business logo and contact information on the top of the NOMNC. Text may not be moved from page 1 to page 2 to accommodate large logos, address headers, etc.
Providers may include information in the optional “Additional Information” section relevant to the beneficiary’s situation.
NOMNC Heading
Contact Information. The contact information should include the name, address and telephone number of the provider that delivers the notice, and it must appear above the title of the form. The provider’s registered logo may be used.
Member Number. Providers may fill in the beneficiary’s/enrollee’s unique medical record or other identification number. The beneficiary’s/enrollee’s HIC number must not be used.
THE EFFECTIVE DATE YOUR {INSERT TYPE} SERVICES WILL END: {Insert Effective Date}. Follow the following guidelines for inserting information into this section of the form:
- Fill in the type of services ending, skilled nursing and the actual date
the service will end. - Note that the date should be in no less than 12-point type.
- If handwritten, notice entries must be at least as large as 12- point type and legible.
Signature Line. The beneficiary/enrollee or the representative must sign this line.
Date. The beneficiary/enrollee or the representative must fill in the date that he or she
signs the document. If the document is delivered, but the enrollee or the representative
refuses to sign on the delivery date, then annotate the case file to indicate the date that
the form was delivered.
Detailed Explanation of Non-Coverage (DENC) CMS-10124
A Medicare provider must deliver a completed copy of this notice to beneficiaries/enrollees receiving covered skilled nursing, home health, comprehensive outpatient rehabilitation facility, and hospice services upon notice from the Quality Improvement Organization (QIO) that the beneficiary/enrollee has appealed the termination of services in these settings. The DENC must be provided no later than close of business of the day of the QIO’s notification.
Alterations to the DENC
Providers may include their business logo and contact information on the top of the DENC. Text may not be moved to a second page to accommodate large logos, address headers, etc.
DENC Heading
Contact Information. The contact information should include the name, address and telephone number of the provider or plan that delivers the notice. This must appear above the title of the form. The entity’s registered logo is not required, but may be used.
Date. Fill in the date the notice is generated by the provider or plan.
Patient Name. Fill in the beneficiary’s/enrollee’s first and last name.
Member Number. Fill in the beneficiary’s/enrollees medical record or identification number. The beneficiary’s/enrollees HIC number must not be used.
{Insert type}. Insert the kind of service being terminated, i.e., skilled nursing, home health, comprehensive outpatient rehabilitation service, or hospice.
Bullet #1. These are the facts used to make the decision. Fill in the patient specific information that describes the current functioning and progress of the beneficiary/enrollee with respect to the services being provided. Use full sentences, in plain English.
Bullet #2. This is a detailed explanation of why the services are no longer covered. Fill inthe details and specific reasons why services are either no longer reasonable or necessary for the beneficiary/enrollee or are no longer covered according to the Medicare guidelines. Describe how the beneficiary/enrollee does not meet the guidelines.
