Changes to SNF Advance Beneficiary Notice of Non-Coverage

The Centers for Medicare and Medicaid Services (CMS) has revised the Skilled Nursing Facility (SNF) Notice of Non-Coverage, Form CMS-10055. With this revision, CMS is discontinuing the five Skilled Nursing Facility (SNF) Denial Letters (the Intermediary Determination of Noncoverage, the UR Committee Determination of Admission, the UR Committee Determination on Continued Stay, the SNF Determination on Admission, and the SNF Determination on Continued Stay) as well as the Notice of Exclusion from Medicare Benefits (NEMB-SNF), Form CMS-20014.

Historically, SNF providers were instructed to issue Form CMS-10055 or one of the five SNF Denial Letters for items and services paid under Medicare Part A to inform fee-for-service Medicare beneficiaries of their potential liability. The NEMB-SNF was used as a voluntary notice to inform beneficiaries of potential liability for items and services that are either subject to statutory denials (i.e. never covered by Medicare) or do not meet technical eligibility requirements (i.e. no qualifying 3-day stay).

Starting May 7, 2018, use of the revised Form CMS-10055 is mandatory. The revised form and detailed instructions are available for download here.

This does NOT change the requirement that homes provide Notice of Medicare Non-Coverage (NOMNC) using Form CMS-10123. Similarly, CMS-R-131, the Advance Beneficiary Notice of Non-Coverage for Medicare Part B items or services that may be denied, will continue to be used.

The new Form CMS-10055 is used for SNFs to transfer financial liability to a fee-for-service Medicare beneficiary for items or services paid under Medicare Part A and must be issued for an item or service that is usually paid for by Medicare, but may not be paid for in this particular instance because it is not medically reasonable and necessary, or custodial care.

More detailed guidance is available in the revisions to Chapter 30 of the Medicare Claims Processing Manual, available here. CMS suggests that providers with questions contact their Medicare Administrative Contractor (National Government Services for New York State).

Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841