Beneficiary Notification Initiative: The information regarding the use of an ABN is according to sections 50.3 - ABN Scope and 50.5 - ABN Triggering Events - from Chapter 30 of the Medicare Claims Processing Manual which is available at the following link: https://www.cms.gov/BNI/Downloads/RevABNManualInstructions.pdf.
The revised ABN is the new CMS-approved written notice that is issued by providers, practitioners, suppliers, and laboratories for items and services provided under Medicare Part A (hospice and regional non-medical healthcare institutes only) and Part B and given to beneficiaries enrolled in the Medicare Fee-For-Service (FFS) program. The revised ABN may not be used for items or services provided under the Medicare Advantage (MA) Program or for prescription drugs provided under the Medicare Prescription Drug Program (Part D). The revised ABN will now be used to fulfill both mandatory and voluntary notice functions.
Notifiers are required to issue ABNs whenever limitation on liability applies. This typically occurs at three points during a course of treatment which are initiation, reduction, and termination, also known as "triggering events".
Initiations
An initiation is the beginning of a new patient encounter, start of a plan of care, or beginning of treatment. If a notifier believes that certain otherwise covered items or services will be noncovered (e.g. not reasonable and necessary) at initiation, an ABN must be issued prior to the beneficiary receiving the non-covered care.
Reductions
A reduction occurs when there is a decrease in a component of care (i.e. frequency, duration, etc.). For example, a beneficiary is receiving outpatient physical therapy five days a week and wishes to continue therapy five days; however, the notifier believes that the beneficiary's therapy goals can be met with only three days of therapy weekly. This reduction in treatment would trigger the requirement for an ABN.
Terminations
Termination is the discontinuation of certain items or services. An example would be when a physical therapist no longer considers outpatient speech therapy described in a plan of care reasonable and necessary. An ABN would have to be issued prior to the termination of the speech therapy. If the beneficiary wishes to continue receiving noncovered speech therapy treatments upon receiving the ABN, he or she must select Option 1 or 2 on the ABN stating that he or she wants to receive the services and agrees to be financially responsible if Medicare does not pay.
The SNF is also required to inform the beneficiary of their rights to an expedited determination. According to CMS, SNFs must give notice to Medicare beneficiaries of their right to expedited determinations when their period of covered care ends. Expedited determinations allow beneficiaries to challenge/appeal their provider's decisions to discharge, whereas the standard appeal process available after a claim is adjudicated allows beneficiaries to dispute payment denials.
Detailed instructions regarding expedited determination notices are found in Chapter One of the Medicare Claims Processing Manual available at the following link: http://www.cms.gov/manuals/downloads/clm104c01.pdf. Providers should note that this requirement applies to the SNF whether the patient is being discharged or remaining in the facility at the termination of SNF level care (when the beneficiary remains technically eligible).
Information regarding the Beneficiary Notification Initiative is available at the following link: www.cms.hhs.gov/BNI. Kris B Harmony recommends utilizing the Quality Indicator Survey Form titled Liability Notices & Beneficiary Appeal Rights Review, available at the following link: https://www.qtso.com/download/qis/forms/CMS-20052_LiabilityNoticesAndAppealsRights.pdf, to monitor the facility's compliance with the expectations of CMS related to the Beneficiary Notification Initiative.