Effective April 30, 2018, skilled nursing facilities (SNFs) must use revised Medicare Skilled Nursing Facility Notice of Non-coverage (Form CMS-10055) to give Medicare beneficiaries advance notice of the facility’s opinion that Medicare Part A will likely not pay for certain services. Concurrently, SNFs may no longer use five SNF Denial Letters (the Intermediary Determination of Non-coverage, the UR Committee Determination of Admission, the UR Committee Determination on Continued Stay, the SNF Determination on Admission and the SNF Determination on Continued Stay), and the Notice of Exclusion from Medicare Benefits (NEMB-SNF), Form CMS-20014.
The new form CMS-10055 is mandatory for anticipated denials of Medicare Part A payment based upon lack of medical necessity or provision of custodial care. In these situations, the Medicare Claims Processing Manual, Chapter 30 imposes many technical requirements for completing and delivering the form to the beneficiary. The Manual discusses beneficiary capacity to receive and understand the form, timing of delivery, role of beneficiary representatives, avoiding beneficiary coercion, as well as many mechanical aspects of filling in the blanks on the form to customize it to the beneficiary’s particular circumstances.
The CMS 10055 also has utility outside of its mandatory function. SNFs may voluntarily use CMS-10055 (or some SNF-drafted variant of it) to notify beneficiaries about other anticipated Medicare Part A denials of payment. Some examples of appropriate voluntary use of the CMS-10055 include lack of a qualifying prior 3 day hospital stay or lack of admission to the SNF within 30 days of a hospitalization. When it is used voluntarily, the technical rules in the Medicare Claims Processing Manual do not apply. For instance, the beneficiary does not need to sign the form and does not need to choose an option about whether to receive the care but pay privately. The form is a courtesy to the beneficiary in these circumstances, and the beneficiary’s response to it will not alter the SNF’s ability to bill the beneficiary for the non-covered service.
SNFs may not use CMS-10055 for anticipated denial of Medicare Part B services. SNFs should use existing Advance Beneficiary Notice of Non-coverage Form CMS-R-131 to notify beneficiaries about anticipated Medicare Part B denials.
When the CMS-10055 form is mandated for anticipated denials of Part A services, it should be used verbatim as posted on the CMS website. If it is altered, the beneficiary may successfully claim that he or she did not receive effective and valid notice. If the notice is ineffective or invalid, the SNF will lose the ability to bill the beneficiary for the denied services.
The stakes for proper use of the CMS-10055 are high, and compliance is therefore important.