Medicare ABN - If patient has other insurance - what is the procedure

Effect of Other Insurers/Payers  

If a beneficiary is eligible for both Original Medicare and Medicaid (dually eligible) or is covered by Original Medicare and another insurance program or payer (such as waiver programs, Office on Aging funds, community agencies (e.g., Easter Seals) or grants), ABN requirements still apply.   For example, when a beneficiary is a dual eligible and receives home health services that are covered only under Medicaid, but are not covered by Medicare for one of the reasons listed in Table 1; an ABN must be issued at the initiation of this care to inform the beneficiary that Medicare will likely deny the services.  

Some States have specific rules regarding HHA completion of liability notices in situations where dual eligible beneficiaries need to accept liability for Medicare noncovered care that Medicaid will cover.  Medicaid has the authority to make this assertion under Title XIX of the Act, where Medicaid is recognized as the “payer of last resort” (meaning other Federal programs like Medicare (Title XVIII) must pay in accordance with their own policies before Medicaid assumes any remaining charges)

On the ABN, the first check box under the “Options” section indicates the choice to bill Medicare and is equivalent to the third checkbox on the outgoing HHABN. HHAs serving dual eligibles should comply with existing HHABN State policy within their jurisdiction as applicable to the ABN unless the State instructs otherwise.

What are cases can HHA give ABN TO beneficiary - time period of ABN

HHA Triggering Events

HHAs may be required to provide an ABN to an Original Medicare beneficiary when a triggering event occurs. Table 2, below, outlines triggering events specific to HHAs.

 Event      Description 

Initiation    When an HHA expects that Medicare will not cover an item and/or service delivered under a planned course of treatment from the start of a spell of illness, OR before the delivery of a one-time item and/or service that Medicare is not expected to cover.

Reduction When an HHA expects that Medicare coverage of an item or service will be reduced or stopped during a spell of illness while continuing others, including when one home health discipline ends but others continue.

Termination When an HHA expects that Medicare coverage will end for all items and services in total.

•  HHA Initiations  

The HHA must issue a beneficiary an ABN prior to delivering care that is usually covered by Medicare,

but in this particular instance, the item or service may not be or is not covered by Medicare because: 

−  The care is not medically reasonable and necessary; 

−  The beneficiary is not confined to his/her home (is not considered homebound);

−  The beneficiary does not need skilled nursing care on an intermittent basis; or 

−  The beneficiary is receiving custodial care only. 

 Note: If the HHA believes that Medicare will not (or may not) pay for care for a reason other than

ones listed directly above, issuance of the ABN is not required.

 

INITIATION EXAMPLE: A beneficiary requires skilled nursing wound care 3 times weekly; however, she is not confined to the home. She wants the care done at her home by the HHA.  The HHA must issue the ABN to this beneficiary before providing the home care that will not be paid for by Medicare. This allows the beneficiary to make an informed decision on whether to receive the non-covered care, and to accept the financial obligation. 

An ABN, signed at initiation of home health care for items and/or services not covered by Medicare, is effective for up to a year; as long as the items/services being given remain unchanged from those listed on the notice. 

•  HHA Reductions  

Reductions involve any decrease in services or supplies, such as frequency, amount, or level of care that an HHA provides and/or that is part of the Plan of Care (POC). If a reduction occurs for an item or service that will no longer be covered by Medicare, but the beneficiary wants to continue to receive the item or service and will assume the financial charges, the HHA must issue the ABN prior to providing the noncovered items or services. (Technically, this is an initiation of noncovered services following a reduction of services).  

REDUCTION WITH SUBSEQUENT INITIATION EXAMPLE: A beneficiary requires Physical Therapy (PT) for gait retraining 5 times per week for 2 weeks, then reduce to 3 times weekly for 2 weeks.  After 2 weeks of PT, the beneficiary wants to continue therapy 5 times a week even though this amount of therapy is no longer medically reasonable and necessary. The HHA would issue an ABN so that he understands the situation and can consent to financial responsibility for the PT not covered by Medicare.

ABN notice for - Home health agency

Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 

This article is based on Change Request (CR) 8404 which provides: 1) instructions for Home Health Agency (HHA) use of the Advance Beneficiary Notice of Noncoverage (ABN) to replace the outgoing Home Health Advance Beneficiary Notice (HHABN), Form CMS-R-296, Option Box 1; 2) ABN issuance guidelines for therapy services and therapy specific examples; and 3) minor editorial changes  to clarify existing manual instructions regarding ABN issuance.

Home health agencies and therapy providers should make sure that their health care and billing staff are aware of these ABN policy changes. All other providers should note that there have been no substantive changes to the ABN form or general instructions for issuance and can reference MM7821 (available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/mm7821.pdf) for general ABN information. 

HHA Use of ABN – General Use

HHAs are required to issue an ABN to Original Medicare beneficiaries in specific situations where “Limitation on Liability” (LOL) protection is afforded under Section 1879 of the Act for items and/or services that the HHA believes Medicare will not cover (see Table 1 below). In these circumstances, if the beneficiary chooses to receive the items/services in question and Medicare does not cover the home care, HHAs may use the ABN to shift liability for the non-covered home care to the beneficiary. 

EDI - rejection - provider specialty code, Expired tax id

 000 ERROR: Provider's specialty code

What this means: The rendering provider information is either incomplete or missing from the   EDI system, or it doesn't match what is being sent on the claim.  

Provider action: Check the rendering provider.  Is it present on the claim?  Is it a provider you have already added to   EDI?  

Rejection Removal: Rejections will not be removed by   EDI as they are valid. 

Re-filing: Once this is corrected, you would want to re-file any

*Expired Tax ID  Dr. XXXXXX

What this means: The tax ID and provider information that the payer has on file is not longer set up in the payer system. 

Provider action: Please contact provider relations at insurance to make sure your provider information is active in their system,

Rejection Removal: Rejections will not be removed by   EDI as they are valid.

Re-filing: Once this is corrected, you would want to re-file any claims that rejected for this reason.

*Wrong Name .

What this means: The provider name being sent on the claim is coming over in first name last name format, ASHN wants it in last name, first name format. 

Provider action: Check the rendering provider.  Is it present on the claim?  How are you sending the name?