Skilled Nursing Facility Advance Beneficiary Notice of Non-

70 - Skilled Nursing Facility Advance Beneficiary Notice of Non- Coverage (SNF ABN) (Rev.: 12758; Issued: 08-01-24; Effective: 10-02-24; Implementation: 10-02-24) The following are the standards for use by Skilled Nursing Facilities (SNFs) in implementing the SNF ABN (CMS-Approved Model Form CMS-10055) requirements. This section provides instructions, consistent with the SNF prospective payment system (SNF PPS), regarding the SNF ABN. SNF ABN - Quick Glance Guide3 Notice Name: SNF ABN Notice Number: CMS-Approved Model, Form CMS-10055 Issued by: SNFs for non-covered SNF PPS extended care items or services. Recipient: Original Medicare fee-for-service (FFS) beneficiary Additional Information: The ABN, Form CMS-R-131 should be used for Medicare Part B non- covered items or services. Type of Notice: Must be issued in order to transfer liability to the beneficiary: Timing of notice: Optional/Voluntary use: Financial liability notice Before SNF PPS extended care items or services are furnished, reduced, or terminated when the SNF, the UR entity, the QIO, or the Medicare contractor believes that Medicare may not pay for, or will not continue to pay for, those extended care services on the basis of one of the following statutory exclusions: • Not reasonable and necessary (“medical necessity”) for the diagnosis or treatment of illness, injury, or to improve the functioning of a malformed body member (§1862(a)(1) of the Act); or • Custodial care (“not a covered level of care”) (§1862(a)(9) of the Act). Prior to delivery of the care item or service in question. Provide enough time for the beneficiary to make an informed decision on whether or not to receive the service or item in question and accept potential financial liability. Yes. It is recommended, but not necessary to transfer liability, for SNFs to issue prior to furnishing a care item or service that is never covered by Medicare (i.e. not a Medicare benefit). 3 This is an abbreviated reference tool and is not meant to replace or supersede any of the directives contained in Section 70.