To find the information below see http://Survey Resources – 06/05/2023 (ZIP)

found: https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/nursing-homes

You will also find when you visit the above website a list of Beneficiary Notice Scenarios for Surveyors to review

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

SNF Beneficiary Notification Review

Beneficiary Notification Review: Complete the review for residents who received Medicare Part A Services.

Medicare beneficiaries have specific rights and protections related to financial liability and the right to appeal a denial of Medicare services under the Medicare Program. These financial liability and appeal rights and protections are communicated to beneficiaries through notices given by providers. This protocol is intended to evaluate a nursing home’s compliance with the requirements to notify Medicare beneficiaries when the provider determines that Medicare Part A coverage is ending or when services may no longer be covered. This review confirms that residents receive timely and specific notification when a facility determines that a resident no longer qualifies for Medicare Part A skilled services when the resident has not used all the Medicare benefit days for that episode. This review does not include Admission notifications or Medicare Part B only notifications.

The two forms of notification that are evaluated in this review are:

1. Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN)—Form CMS-10055; and
2. Notice of Medicare Non-coverage (NOMNC) — Form CMS-10123.

Entrance Conference Worksheet: The following information was requested during the Entrance Conference:

A list of Medicare beneficiaries who were discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months prior to the survey. Exclude the following residents from this review:

• Beneficiaries who received Medicare Part B benefits only.
• Beneficiaries covered under Medicare Advantage insurance.
• Beneficiaries who expired during the sample date range.
• Beneficiaries who were transferred to an acute care facility or another SNF.Review Three Notices:Randomly select 3 residents from that list. We recommend selecting one resident who went home and two residents who remained in the facility, if available.Fill in the name of the selected residents at the top of each Beneficiary Notification Checklist.Give the provider one Beneficiary Notification Checklist for each of the three residents to complete and return to the surveyor.The provider completes one checklist for each of the three residents in this sample and returns the checklist and notices to the survey team.Review the checklists and notices with the provider.

 

1. Were appropriate notices given to the residents reviewed? Yes No F582 NA

SNF Beneficiary Notification Review for Residents who Received Medicare Part A Services

Facility Representative: Please complete all fields of this form. The intent of the checklist is to provide the surveyor with all copies of the forms issued to the resident, and if the notification was not required, an explanation of why the form was not issued.

Resident Name: ___________________________________________________ Medicare Part A Skilled Services Episode Start Date: ___________________ Last covered day of Part A Service: _____________

FORM CMS-20052 (10/2022)

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

SNF Beneficiary Notification Review

(Part A terminated/denied or resident was discharged)How was the Medicare Part A Service Termination/Discharge determined? Voluntary, i.e., self-initiated in consultation with physician, family, or AMA.The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted.Other (explain):
1. Was a SNF ABN, Form CMS- 10055 provided to the resident?	? Yes ?If yes, provide a copy of the form(s) that were acknowledged by the beneficiary or the beneficiary’s representative.? No ?If no, explain why the form was not provided: ? The resident was discharged from the facility and did not receive non-covered services.? Other Explain:?*If NOT issued and should have been: cite F582
2. Was a NOMNC, Form CMS- 10123 provided to the resident?	? Yes? If yes, provide a copy of the form(s) that were acknowledged by the beneficiary or the beneficiary’s representative.? No ? If no, explain why the form was not provided: ? 1. The beneficiary initiated the discharge. If the beneficiary initiated the discharge, provide documentation of these circumstances (examples: Resident asked doctor to go home, got orders, & discharged in the same day; Resident discharged AMA).? 2. Other Explain:?*If NOT issued and should have been: cite F582

FORM CMS-20052 (10/2022

The information presented is informative and does not constitute direct legal or regulatory advice

September 2024\Skilled Nursing Support\maria.messina@skillednursingsupport.com

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