Master Core Curriculum

1. Master Core Curriculum Medicare Part A Intermediate Module 4 Advance Beneficiary Notice

2. ABN Advance Beneficiary Notice FLP Financial Liability Protections FI Fiscal Intermediary CMS Centers for Medicare & Medicaid Services NF Nursing Facility HHABN Home Health Advanced Beneficiary Notice HINN Health Insurance Notice of Non-coverage SNF Skilled Nursing Facility Acronyms

3. EMTALA Emergency Medical Treatment and Active Labor Act MSE Medical Screening Examination QIO Quality Improvement Organization ADR Additional Development Request NEMB Notices of Exclusions from the Medicare Benefit COP Conditions of Participation Acronyms

4. Learning Outcomes At the end of the module, participants will be able to: • identify patient liability situations where the ABN is required • describe demand bills • administer the ABN correctly • submit a correctly coded claim in ABN situations

5. What is an ABN? • It is a written notice given to a beneficiary (or authorized representative) by a provider of services when the care is physician-ordered and is believed that Medicare would not payfor some or all services or items • Primarily on the basis of not being medically necessary

6. What purpose does the ABN serve the beneficiary? • Allows a Medicare beneficiary to • Decide • Info is given to the beneficiary so that a informed decision can be made for receiving services or items that may not be covered • Appeal • Medicare’s decision about non-coverage

7. What purpose does the ABN serve the beneficiary? • Notifies the beneficiary of their personal financial responsibility when it is believed Medicare will not pay for a particular service/item • If the notice is properly given, it protects a provider by shifting the financial liability to the beneficiary

8. Who is authorized to sign the ABN? • Beneficiary, or legal representative • Spouse, unless legally separated • Adult child • Parent • Adult sibling • Close friend

9. What happens if the beneficiary refuses to sign the ABN? • Have a second witness of the refusal to sign • Someone in addition to the provider • Beneficiary cannot properly refuse to sign and still demand the item or service • Provider should consider not furnishing the item or service unless the consequences are such that this is not an option • Financial responsibility may rest with the beneficiary if services are rendered

10. ABN Forms • The standard ABN form • Form CMS-R-131 • There are two CMS-R-131 forms • ABN-G • The General Use form • ABN-L • The Laboratory Tests form • Pub. 100-4, Section 50 of Chapter 30

11. ABN Forms • Form CMS-R-296 • Home Health Advance Beneficiary Notice (HHABN) • Pub. 100-4, Section 60 of Chapter 30 • Form CMS-10055 • A new SNF ABN form for use by SNFs and should not be modified • Pub. 100-4, Section 70 of Chapter 30

12. ABN Forms • Do not use • Italics • Fonts that are hard to read • Anything less than a 12-point font • Block-shaded text • Do use • Dark ink on a pale background • Black or dark blue on white background preferred

13. Language Be specific Write without jargon Write in a language that is easily understood Signature Ensure the ABN is signed by the beneficiary or an authorized representative ABN Forms

14. NEMB • Providers use when billing for a denial for excluded items and services • An ABN is usually NOT used for these services • Does not require a signature

15. NEMB Forms • Standard Form • Form CMS-20007 • Pub. 100-4, Section 90 of Chapter 30 • Home health NEMB form • Form CMS-10111 • Pub. 100-4, Section 60 of Chapter 30 • SNF NEMB form • Form CMS-20014

16. When to give an HHABN • Services not medically reasonable or necessary • Custodial care only • Non-skilled personal care • Helping with daily living activities such as: bathing, dressing, eating, getting in and out of bed, using the bathroom • Patient no longer homebound

17. Will Medicare deny payment for this service (or item)? • Three possible answers • “No, I do not expect Medicare to deny payment” • “I don’t know. I never know what Medicare will deny” • “Yes, I have a genuine reason to expect that Medicare will deny payment, based on other Medicare denials, local medical review policies (LMRPs), local standards of medical practice, etc.”

18. If the answer is “no” or “I don’t know” • Do not give an ABN but do submit a claim to Medicare • If Medicare pays: • Collect charges from Medicare • Collect any coinsurance & deductible from the patient • If Medicare denies payment for medical necessity • Provide initial documentation of medical necessity so that Medicare will pay • Appeal on the basis that the service should be covered • Appeal on the basis that you did not know and could not reasonably have been expected to know that Medicare would not pay

19. If the answer is “no” or “I don’t know” con’t… • If Medicare denies payment on the basis of a statutory exclusion or failure to meet technical coverage requirements under the program benefits section of the law • Collect the full charges from the patient

20. If the answer is “yes” • Then, ask this question: "On what basis do I expect that Medicare will deny payment?” • Medical necessity • Do give an ABN • If the patient receives the services or items you must always submit a claim to Medicare (it is called a "demand bill") • If you do not submit a claim, timely, you violate the mandatory claims submission provision, which can result in sanctions

21. Medical Necessity “Demand Bill” • After you have submitted a “demand bill”: • If Medicare pays • Collect payment from Medicare, and any coinsurance & deductible from the beneficiary • If Medicare denies payment • You may collect full charges from the beneficiary

22. If the answer is “yes” con’t… • Then, ask this question: "On what basis do I expect that Medicare will deny payment?” • Exclusions & technical denials - • Do not give an ABN • You do not need to submit a claim unless the patient demands it • If you do not submit a claim, you may collect full charges from the patient

23. Exclusions or Technical Denial “Demand Bill” • If you submitteda “demand bill”: • If Medicare pays • Collect payment from Medicare, and any coinsurance & deductible from the beneficiary • If Medicare denies payment • You may collect full charges from the beneficiary

24. EMTALA • Has a Medical Screening Examination [MSE] by a qualified individual been completed? • NO • Do not give an ABN • First, complete an MSE • If you do not complete an MSE, no ABN may be given. • Stabilize the beneficiary • Then give an ABN, but only if appropriate

25. EMTALA • Has a qualified individual completed an MSE? • Yes • Is the beneficiary stabilized? • NO • Stabilize the beneficiary • Give an ABN, but only if appropriate • YES • Give an ABN, but only if appropriate

26. EMTALA • Do notroutinely give ABNs to all emergency department patients who are Medicare beneficiaries • Even after a patient has received an MSE and is stabilized, donotgive the patient an ABN unlessyou have a genuine reason to expect Medicare to deny payment for the services • Giving routine ABN notices is a prohibited practice

27. Demand Bills • Patient may request a demand bill be sent to the FI for an official Medicare claim determination for the services deemed non-covered by the provider • The provider would submit a demand bill along with documentation to substantiate its belief in services that may not be covered and wait for determination from the review team. • Patient may be billed once the claim has been submitted to Medicare for determination

28. Demand Bill Coding • Condition Code 20 • Charges (in dispute) must be in the non-covered column • Frequency code zero should be used if all services on the claim are non-covered • CC 20 and occurrence code 32 are NEVER submitted on the same claim; and • Basic claim elements must be completed

29. Claims billed with an ABN: Never use a CC 20 or 21 Use a claim-level occurrence code (OC) 32 Signifies all services on claim associated with one ABN unless use of modifiers indicate not all lines on claim are linked to the ABN OC 32 and accompanying date must be used multiple times if more than one ABN is tied to a single claim for services that must be billed/bundled on the same claim Provide the date ABN signed Submit all ABN-related services as covered charges; and Complete all basic required claim elements 29

30. GA Modifier Used when Medicare providers must bill services related and not related to an ABN on the same claim Both covered and non-covered services may appear on the ABN-related claim 30

31. Demand Bill for Routine Services Claim requirements Condition Code (CC) 20 must be used All charges associated with CC 20 must be submitted as non-covered Frequency code zero should be used if all services on the claim are non-covered CC 20 and occurrence code 32 are NEVER submitted on the same claim; and Basic required claim elements must be completed 31

32. Condition Code 21 Service Non-covered By Statute When an ABN is not appropriate Providers may elect to use the NEMB in order to voluntarily notify beneficiaries of their potential liability for services excluded by statute The NEMB helps insure COPs that MAY require a provider to inform the beneficiary of payment liability BEFORE delivering services not covered by Medicare, are being met 32

33. References • CMS website • Internet Only Manual • CMS Claims Processing Manual, Chapter 30 • http://www.cms.hhs.gov/medlearn/dpinfo.asp • http://cms.hhs.gov/medlearn/refabn.asp