May 12, 2020 - Updated 06.18.20
Skilled Nursing Facility (SNF) Demand Bills
CGS is still processing SNF demand bills. Please submit the medical record within 45 days of the request and ensure the following documentation is included within the requested information along with a copy of the additional documentation request (ADR) letter:
| Check | SNF Demand Bill ADR Checklist – Preferred Order |
|---|---|
| 1. ADR letter or FISS Page 7 screenprint | |
| 2. Hospital discharge/transfer summary/MD discharge summary | |
| 3. SNF admission history and physical | |
| 4. MD Cert/Recert for skilled level of care | |
| 5. All MD orders for claim period and 30 days prior | |
| 6. All physician progress notes for claim period and 30 days prior | |
| 7. All MDS's from admission thru claim dates | |
| 8. Nurses notes, med admin records, wound care records, VS/I&O/weights, and treatment records for claim period and 30 days prior | |
| 9. All therapy documentation for claim period and 30 days prior (include Certs/Recerts/treatment plans/progress notes and logs) | |
| 10. Copy of letter of Non-coverage and consent for placement in Non-Medicare covered bed (applicable SNF Advance Beneficiary Notice of Noncoverage (ABN) and Notice of Medicare Non-Coverage (NOMNC) | |
| 11. Other relevant documentation |
When does a SNF Advance Beneficiary Notice of Noncoverage (ABN) or Notice of Medicare Non-Coverage (NOMNC) need to be completed?
When the SNF determines that a patient no longer meets a Medicare skilled level of care upon admission or at some point during the SNF stay, the patient or their representative must be notified via the SNF Advance Beneficiary Notice of Noncoverage (ABN).
The SNF ABN will include the determining factor/reason that the Medicare skilled level of care was not met upon admission or is no longer met during the stay, and that you anticipate the services will not be payable by Medicare. The SNF ABN must be signed and dated by the patient or their representative and this date must reflect when the patient or their representative was first notified of this determination.
If a phone call notification is made to the patient or their representative prior to signing the letter, there must be documentation of the date and time the call was placed, the name of the individual that placed the call, and who was informed. Please include the documented verification that the follow-up letter was sent via 'registered mail' with a return receipt, include the mail receipt and a copy of the envelope.
If the physician has accepted the notion that skilled services are no longer needed or it is appropriate to reduce these services, then the use of the NOMNC is appropriate. The NOMNC is used in place of the ABN in order to transfer financial liability to the beneficiary. If the skilled services are not reduced or terminated in accordance with a physician's order, then the ABN is required.
CMS Internet Only Manual (IOM) (SNF ABN and NOMNC details)
Publication 100-04, Claims Processing Manual, Chapter 30, Section 70
What is the purpose of a SNF ABN or NOMNC?
The purpose of the SNF ABN is to inform a beneficiary before receiving services or items that may otherwise be covered, that Medicare will not, or most likely will not, pay for the services or items for a particular reason. This allows the beneficiary to make an informed choice to either receive the services or not. The SNF ABN also allows the beneficiary the option to have the potentially non-covered charges submitted to a review by a Medicare Administrative Contractor (MAC) for payment in the form of a Demand Bill.
The NOMNC is issued prior to the termination of all Medicare covered skilled services in accordance with a physician order to discontinue these services. A NOMNC must be delivered even if the beneficiary agrees with the termination of services. The notice informs the beneficiary of the right to request a Quality Improvement Organization (QIO) review of the discharge and explains how the beneficiary can request an expedited determination from the QIO.
CMS Form Instructions for the NOMNC
When should a facility submit a SNF demand bill?
After receiving notification that the beneficiary or their representative does not agree with the determination that a patient no longer requires or meets a Medicare skilled level of care, they may request Medicare process the claim. This is referred to as a demand bill.
Do not submit demand bills for every patient whose care drops below the Medicare skilled level, or for those patients upon admission do not meet the level of care criteria.
A request for a demand bill may also be sent at the request of the state where the patient resides for Medicaid coverage purposes. This review is conducted in the same way as for a beneficiary requested demand bill.
How to submit a SNF demand bill?
The demand bill (noncovered claim with condition code 20) should be billed with a default code at the default rate. Please submit the claim electronically during the regular billing cycle. An additional documentation request (ADR) letter will be sent to the provider requesting the information necessary to complete the demand bill review and the claim will suspend for medical review. The ADR will inform the provider of the address to send this information.
Be sure to include the applicable medical records and documents along with a copy of the NOMNC or SNF ABN requesting the review, signed and dated (date of first notification) by the beneficiary or their representative (and return receipt if sent via registered mail).
When can the facility bill the patient?
The facility may not bill the patient prior to receipt of the Medicare Administrative Contractor (MAC) decision on the demand bill (except for non-covered items such as hair care, television or telephone).
For more information, visit:
CMS IOM
Publication 100-04, Claims Processing Manual, Chapter 1, Section 60.3.2
CMS IOM
Publication 100-04, Claims Processing Manual, Chapter 6, Section 40.9
CMS MLN
MM10567 - Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN)
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