Question

1. What are the four types of Advance written notices of noncoverage?
2. What are the three "triggering events" that may prompt issuance of an advance written notice of noncoverage?
3. What are the claim reporting modifiers associated with the ABN?
4. As it relates to financial liability, when an advance written notice of noncoverage is required and it is not issued a notice is the patient liable for paying for the services?
5. Identify a reason when you should not use an advance written notice of noncoverage?

Answer 1

1)types of advance written notice of non cove rages:

• Advance beneficiary notice of non coverage. This must be delivered by all healthcare providers & suppliers. Form CMS-R-131, when there is denial of Medicare payment to transfer the financial liability to the beneficiary. This can help the beneficiary to decide whether to get the item or service Medicare that may not cover & accept financial responsibility to pay for it. If the beneficiary does not get written notice when it is required, they may not be financially liable if Medicare denies payment, and the provider or supplier may be financially liable instead.
• Skilled nursing facility advance beneficiary notice of non coverage. This is issued in order to transfer the financial liability to the beneficiary. Form CMS-10055, before providing part a item or service to a beneficiary Medicare usually pays but doesn’t pay if it is medically unnecessary or a custodial care.
• Hospitals issue a Hospital-Issued Notice of Noncoverage (HINN) prior to admission, at admission, or at any point during an inpatient stay if hospitals determine the beneficiary’s care is not covered because it is: Medically unnecessary Not delivered in the most appropriate setting Custodial in nature.
• Home health change of care notice. This is issued by home health agencies to notify the beneficiary about plan of care changes.

2) Following are three events that prompt issuance of advance written notice of non coverage:

• Initiations: this occurs at the beginning of new patient encounter or start of POC or beginning of the treatment. Under this Medicare will not cover certain items or services because they are not reasonable or necessary. But a notice must be issued before the beneficiary is receiving a non covered care.
• Reductions: this can occur when a component of care decreases. The notice must not be issued every time when there is reduction in the care. If the reduction occurs & beneficiary wants to no longer continue receiving the care then a notice must be issued prior to furnishing of non covered care.
• Terminations: Terminations discontinue all or certain items or services. If services are terminated and the beneficiary wants to continue receiving care no longer considered medically reasonable and necessary, you must issue the notice prior to furnishing non covered care.

3) Following are the claim modifiers associated with the ABN:

• GA: this is waiver of liability statement that is issued as required by payer policy. When a mandatory ABN for service as required & is on file. a copy need not be submitted but must be available on request.
• GX: notice of liability issued voluntary under payer policy. Report when you issue a voluntary ABN for a service. Medicare never covers because it is statutorily excluded or is not a Medicare benefit. You may use this modifier in combination with modifier GY.
• GY. This item or service is statutorily excluded & doesn’t meet the definition of any Medicare benefit. Report that Medicare statutorily excludes the item or service, or the item or service does not meet the definition of any Medicare benefit. You may use this modifier in combination with modifier GX.
• GZ. This item or service is expected to be denied. Report when you expect Medicare to deny payment of the item or service due to a lack of medical necessity and no ABN was issued.

4) If the beneficiary does not get written notice when it is required, they may not be financially liable if Medicare denies payment, and the provider or supplier may be financially liable instead.

5) You cannot issue an advance written notice of noncoverage to:

● Shift liability and bill the beneficiary for the services denied due to a Medically Unlikely Edit (MUE).

● A beneficiary in a medical emergency or under great duress (compelling or coercive circumstances). Advance written notice of noncoverage use in the emergency room or during ambulance transports may be appropriate in some cases (for example, a beneficiary who is medically stable and not under duress).

● Charge a beneficiary for a component of a service when Medicare makes full payment through a bundled payment.

● Transfer liability to the beneficiary when Medicare would otherwise pay for items and services.