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Part III - Instructions for Fiscal Intermediaries and Providers on Advance Beneficiary Notice (ABN) Standards for Items and Services for Which Institutional Part B Claims Will Be Processed by Fiscal Intermediaries and on Limits on Beneficiary Liability for Medical Equipment and Supplies
Section III.1. Incorporation by Reference of Part I & Part II of this PM.--
A. Physicians, suppliers, and providers, and the fiscal intermediaries processing their claims, must follow the general requirements for ABNs as they are enunciated in Part I of this PM and, as applicable, the general requirements for implementing limits on beneficiary liability for medical equipment and supplies (the DMEPOS Refund Requirements) as they are enunciated in Part II of this PM. With respect to demand bills, they must follow the instructions in Part III of this PM.
B. These instructions on the use of ABNs apply to all claims for Part B items and services furnished by institutional providers and/or processed by fiscal intermediaries (inclusive of, e.g., Part B claims submitted by a physician or other supplier for processing by a fiscal intermediary, Part B claims for medical and other health services furnished by an HHA, Part B claims for certain items and services when furnished by a participating SNF (either directly or under arrangements) to an inpatient of the SNF, if payment for these services cannot be made under Part A). Providers must utilize ABN procedures for these Part B items and services furnished to Medicare beneficiaries, including dually- eligible (e.g., Medicare and Medicaid) beneficiaries. They must not give inpatient notices of noncoverage (e.g., Notices of Non-Coverage/Hospital Issued Notices of Noncoverage NONCs/HINNs) to beneficiaries for Part B items and services. They must not give Medicare ABNs to patients who are not Medicare beneficiaries.
Section III.2. ABNs for Medical and Other Health Services Furnished by an Home Health Agency (HHA) under Part B.--Part B of Medicare is designed to supplement the basic Part A coverage. In addition to providing coverage for unlimited home health visits in a calendar year (see HHA Manual §215.2), Part B provides coverage for certain “medical and other health services.” Reimbursement may be made to an HHA that furnishes, either directly or under arrangements with others, certain medical and other health services (see HHA Manual §219). The instructions in Part I and Part II of this PM are applicable with respect to Part B claims for medical and other health services furnished by an HHA.
Section III.3. ABNs for Part B Services Furnished in a Skilled Nursing Facility (SNF).-- Insofar as (per SNF Manual §260.A) payment may be made under Part B for certain items and services when furnished by a participating SNF (either directly or under arrangements) to an inpatient of the SNF, if payment for these services cannot be made under Part A (e.g., the beneficiary has exhausted his/her allowed days of inpatient SNF coverage under Part A in his/her current spell of illness or was determined to be receiving a noncovered level of care, or the 3-day prior hospitalization or the transfer requirement is not met), the instructions in Part I and Part II of this PM are applicable with respect to such Part B claims. (See also SNF Manual §529 and §534.)
Section III.4. Demand Bills.--A demand bill is a complete, processable claim which must be submitted promptly to Medicare by the physician, supplier or provider at the timely request of the beneficiary, the beneficiary's representative, or, in the case of a beneficiary dually entitled to Medicare and Medicaid, a State as the beneficiary’s subrogee. A demand bill is requested usually, but not necessarily, pursuant to notification of the beneficiary (or representative or subrogee) of the fact that the physician, supplier or provider expects Medicare to deny payment of the claim. When the beneficiary (or representative or subrogee) selects an option on an ABN that includes a request that a claim be submitted to Medicare, no further demand is necessary; a demand bill must be submitted.
A. The physician, supplier or provider always must submit a claim, billing as covered, for an initial determination when it gave an ABN on the basis of the likelihood of denial of payment. On such a claim, the physician, supplier or provider must enter occurrence code 32 on the UB-92 in one of the fields numbered 32 through 35. This code indicates the date the physician, supplier or provider gave the ABN to the beneficiary. It is the occurrence code 32, and not any condition code that indicates to the fiscal intermediary that an ABN has been issued. Occurrence code 32 is mandatory; it must be used anytime a signed ABN was obtained.
B. A physician, supplier or provider that has obtained a signed ABN (form CMS- R-131) shall not enter condition code 20 (the demand bill condition code) on the UB-92.Condition code 20 is never to be used when an ABN (form CMS-R-131) has been obtained; only occurrence code 32 shall be used. The fiscal intermediary must not routinely deny payment for services billed with occurrence code 32. The provision of an ABN by the physician, supplier or provider only represents its assessment that Medicare will deny payment. The fiscal intermediary must make its initial determination on the usual bases, without being influenced by occurrence code 32 being on the claim. After the fiscal intermediary has denied payment on a claim, it must take into account the presence of occurrence code 32 in determining the liability of the beneficiary and the physician, supplier or provider with respect to those specific item(s) and/or service(s) for which the ABN was given and signed. Occurrence code 32 removes any need for physicians, suppliers or providers to routinely submit copies of ABNs to the fiscal intermediary which does not need to review actual ABNs unless there is a complaint or allegation of improper use of the ABN which it must investigate. When an occurrence code 32 is included on a claim, the fiscal intermediary shall not routinely require the physician, supplier or provider to also submit a copy of the ABN.
C. The physician, supplier or provider may submit claims, for initial determination, for statutorily excluded services, if the beneficiary requests it. On claims for statutorily excluded services, the physician, supplier or provider should enter a condition code 21 on the UB-92 in one of the fields numbered 24 through 30 to indicate that it realizes that the furnished services are excluded, but that it is requesting a denial notice from Medicare in order to bill Medicaid or other insurers. This is also known as a “no-pay” claim. The fiscal intermediary must handle such a claim in the same manner as it handles all other claims with condition code 21 entered on them. |
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