RG – Beneficiary Notices / Coverage-(ABN NOMNC)

• • • Hospices are required to provide a Notice of Medicare Non-Coverage (NOMNC) expedited determination notices are given to beneficiaries when all Medicare covered services are being terminated when no longer terminally ill  Hospice must provide the Notice of Medicare Provider Non-Coverage (Generic Notice) to Medicare beneficiaries no later than two days before the effective date of the end of the coverage that their Medicare coverage will be ending.*  The NOMNC informs beneficiaries on how to request an expedited determination from their Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) and gives beneficiaries the opportunity to request an expedited determination from a BFCC-QIO.  The BFCC-QIO will request medical records from the hospice.
    • The Detailed Notice of Hospice Non-Coverage (DN) and Advanced Beneficiary Notice (ABN) are issued together only when all covered care is being terminated and beneficiary is expected to continue receiving noncovered care. A Detailed Explanation of Non-Coverage (DENC) is given only if a beneficiary requests an expedited determination. The DENC explains the specific reasons for the end of covered service. Generally, the BFCC-QIO’s review will be completed within 72 hours of the BFCC-QIO’s receipt of the beneficiary’s request for a review.

Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) work under contract with the Centers for Medicare & Medicaid Services (CMS) to provide services to people with Medicare.  BFCC-QIOs help Medicare beneficiaries exercise their right to high-quality health care. They handle cases in which beneficiaries want to appeal a health care provider’s decision to discharge them from the hospital or discontinue other types of services. Two designated BFCC-QIOs serve all 50 states and three territories, which are grouped into ten regions.

*If state regulations for discharge notice require more than 2 days’ notice, the provider is required to follow the most stringent regulation.

NHPCO Member Resources and Compliance Guides

• • • Advance Beneficiary Notice of Non-Coverage (ABN) and Notice of Medicare Non-Coverage in Hospice (NOMNC) Compliance Guide (February 2022)
    • Submit Records to QIO Electronically – FAQs October 2020 

Regulations

• • • Hospice Care Code of Federal Regulations 42CFR 411

Subpart K §411.404

• • • • • • • 404 Payment for Certain Excluded Services (govregs.com)

Subregulatory Guidance

• • • Medicare Benefit Policy Manual Chapter 9-Coverage of Hospice Services Medicare Benefit Policy Manual (cms.gov)

Section 20.2.3 - Hospice Discharge

• • • Medicare Claims Processing Manual Chapter 30 - Financial Liability Protections Medicare Claims Processing Manual (cms.gov)

Section 260 - Expedited Determinations of Provider Service Terminations

Other Resources

• • • Hospice Guidelines for the Advance Beneficiary Notice of Noncoverage (ABN) (cgsmedicare.com)
    • Locate Your QIO
    • CMS FFS Expedited Determination Notices webpage
    • Medicare Advance Written Notices of Noncoverage (cms.gov)

Cross Reference

• • • Billing and Reimbursement
    • Discharges, Transfers and Revocations
    • Election and Admission

Alerts/Newsbriefs/Newsline
(Nothing applicable at this time)

Education

• • • Webinars/On-Line Learning/Conferences
      (Nothing applicable at this time)
    • Podcasts
      (Nothing applicable at this time)

Marketplace

• • • Hospice Discharge, Revocation, and Change of Hospice (2019)
      This handy, travel-sized Hospice Discharge, Revocation, and Change of Designated Hospice is a resource of Process Maps to Guide Hospice Providers including when to issue a NOMNC, DENC and ABN.

The Centers for Medicare and Medicaid require a provider to notify Medicare beneficiaries when a service may not be covered under the Medicare program. The Advance Beneficiary Notice of Non-Coverage must be completed by the provider, or their representative, and signed by the patient before a service is rendered.

The ABN advises the patient that the service they are about to receive may not be covered by Medicare. The form must include a description of the service, along with the estimated out-of-pocket cost and the reason why Medicare may potentially deny the service. The services itemized on the form must be clearly explained to the patient (or their representative).  Thus, the ABN allows the patient to make an informed decision regarding whether or not to receive the service.

Mandatory use of the ABN is very limited for hospices. Hospice providers are responsible for providing the ABN when required as listed below for items and services billable to hospice. Hospices are not responsible for issuing an ABN when a hospice patient seeks care outside of the hospice’s jurisdiction.

The three situations that would require issuance of the ABN by a hospice are:

1. 1. 1. Ineligibility because the beneficiary is not determined to be “terminally ill” as defined in §1879(g)(2) of the Act;
      2. Specific items or services that are billed separately from the hospice payment, such as physician services, are not reasonable and necessary as defined in either §1862(a)(1)(A) or §1862(a)(1)(C); or
      3. The level of hospice care is determined to be not reasonable or medically necessary as defined in §1862(a)(1)(A) or §1862(a)(1)(C), specifically for the management of the terminal illness and/or related conditions.

NHPCO Member Resources and Compliance Guides

• • • Advance Beneficiary Notice of Non-Coverage (ABN) and Notice of Medicare Non-Coverage in Hospice (NOMNC) Compliance Guide (February 2022)

Regulations

• • • Hospice Care Code of Federal Regulations 42CFR 411
      Subpart K §411.404
      • • 404 Payment for Certain Excluded Services (govregs.com)
    • Hospice Code of Federal Regulations 42CFR Subpart J 405.1200 Notifying Beneficiaries of Provider Service Terminations

Subregulatory Guidance

• • • Supporting Statement for the Extension of the ABN (Sept. 2022)
    • ABN Form Instructions (Sept. 2022)
      • • ABN Form (English) (Sept. 2022)
        • ABN Form (Spanish) (Sept. 2022)

• • • Medicare Benefit Policy Manual Chapter 9-Coverage of Hospice Services Medicare Benefit Policy Manual (cms.gov)

50 - Limitation on Liability for Certain Hospice Coverage Denials

• • • Medicare Claims Processing Manual Chapter 11 - Processing Hospice Claims Medicare Claims Processing Manual (cms.gov)

Section 100.2 - Demand Billing for Hospice General Inpatient Care

• • • Medicare Claims Processing Chapter 1 General Billing Requirements Medicare Claims Processing Manual (cms.gov)

Section 60.4.1 Outpatient Billing with an ABN (Occurrence Code 32)

Other Resources

• • • • Hospice Guidelines for the Advance Beneficiary Notice of Noncoverage (ABN) (cgsmedicare.com)
      • CMS FFS ABN webpage
      • Advance Beneficiary Notice of Non-coverage Interactive Tutorial Educational Tool.
      • Medicare Advance Written Notices of Noncoverage (cms.gov)

Cross Reference

• • • Billing & Reimbursement
    • Discharges, Transfers & Revocations
    • Election & Admissions

Alerts/Newsbriefs/Newsline
Nothing applicable at this time 

Education

• • • Webinars/On-Line Learning/Conferences
      Nothing applicable at this time 
    • Podcasts
      Nothing applicable at this time 

Marketplace

• • • Hospice Discharge, Revocation, and Change of Hospice (2019)
      This handy, travel-sized Hospice Discharge, Revocation, and Change of Designated Hospice is a resource of Process Maps to Guide Hospice Providers including when to issue a NOMNC, DENC and ABN.