Ask the Nursing Expert about ...Medicare denial forms

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Judi Kulus, VP of Curriculum Development, AADNS
Judi Kulus, VP of Curriculum Development, AADNS

I've heard that as of April 30, 2018, we had to start using the new CMS-approved form for Medicare A denial notices. As a director of nursing services, what do I need to know?

Most skilled nursing facilities use one of CMS's five 20-year-old denial letters to inform beneficiaries they no longer qualify for skilled care. But that process is changing.

As of April 30, CMS mandates use of the redesigned SNFABN 10055 form, which was released as optional nearly 10 years ago.

This is in addition to the current Notice of Medicare Non-Coverage (CMS-10123), also known as the Generic Notice. The new CMS-10055, required when a resident is being taken off Medicare and staying in the facility, notifies the resident that he/ she is responsible for paying for his/ her care after the date on the notice. CMS-10123, required at least 48 hours before the last covered day, gives the resident the opportunity to immediately appeal the non-coverage decision to the Quality Improvement Organization.

Confusion can arise over certain residents who elect hospice in the SNF. When a resident or responsible party chooses to begin hospice, the facility's clinical team must decide whether the resident qualifies for dual coverage with Medicare A while on hospice. Although dual coverage is unusual and seldom appropriate, it is possible; therefore, the resident and/ or family must be given the opportunity to appeal a decision to end Medicare A coverage when hospice begins.

Hospice or not, as of April 30, when Medicare A coverage ends with Medicare days remaining and the resident continues living in the facility, the new SNFABN 10055 notice must be given. Staff should note the 2018 designation on the lower left of the new form and remove all other denial cut letters from their systems.

Please send your nursing-related questions to Judi Kulus at ltcnews@mcknights.com.