CMS Pub. 100-04, ch. 30, § 500

The following terms are defined only for purposes of this Chapter 30 of the

Medicare Claims Processing Manual.

Advance notice of non -coverage– 42 CFR 418.408(d)(2) states that if

Medicare would be likely to deny payment as not medically reasonable and

necessary, before the service was provided, the physician informed the

beneficiary, or someone acting on the beneficiary's behalf, in writing that the

physician believed Medicare was likely to deny payment for the specific service

and that the beneficiary signed a statement agreeing to pay for that service. This

statement may appear as the notice of non-coverage (e.g.

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

Skilled

Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN),

Form CMS10055, Home Health Change of Care Notice (HHCCN), Form

CMS-10280), as defined in 42 CFR 411.404.)

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

Issued by healthcare providers and suppliers to Original Medicare (fee for

service) beneficiaries in situations where Medicare payment is expected to be

denied.

Authorized representative – An individual authorized under State or other

applicable law, e.g., a legally appointed representative or guardian of the

beneficiary (if, for example, the beneficiary has been legally declared

incompetent by a court) to act on behalf of a beneficiary when the beneficiary

is temporarily or permanently unable to act for himself or herself. The

authorized representative will have all of the rights and responsibility of a

beneficiary or party, as applicable. In states which have health care consent

statutes providing for health care decision making by surrogates on behalf of

patients who lack advance directives and guardians, reliance upon individuals

appointed or designated under such statutes to act as authorized

representatives is permissible. The Appointment of Representative, Form

CMS-1696 is available for the convenience of the beneficiary or any other

individual to use when appointing a representative.

For purposes of this chapter, when the term beneficiary is used, for legal

purposes, and the beneficiary has an authorized representative, the use of

either beneficiary or authorized representative are exchangeable of each other,

unless otherwise indicated.

Beneficiary – Individual who is enrolled to receive benefits under Medicare

Part A and/or Part B.

Detailed Explanation of Non-Coverage (DENC, Form CMS-10124) –

Medicare FeeFor-Service (FFS) Expedited Determination Notice given only if

a beneficiary requests an expedited determination. The DENC explains the

specific reasons for the end of services.

Detailed Notice of Discharge (DND, Form CMS-10066) – Hospital

Discharge Appeal Notice given to beneficiaries who choose to appeal a

discharge decision from the hospital or their Medicare Advantage plan, if

applicable.

Financial Liability Protections (FLP) Provisions – The FLP provisions of

the Social Security Act protect beneficiaries, healthcare providers, and

suppliers under certain circumstances from unexpected liability for charges

associated with claims that Medicare does not pay. The FLP provisions apply

after an item or service’s coverage determination is made.

Healthcare provider – Healthcare provider means a “provider of services”

(or provider) (as defined under Section 1861(u) of the Social Security Act), a

hospital, a critical access hospital (CAH), a skilled nursing facility (SNF), a

comprehensive outpatient rehabilitation facility, a home health agency, or a

hospice that has in effect an agreement to participate in Medicare, or a clinic, a

rehabilitation agency, or a public health agency that has in effect a similar

agreement but only to furnish outpatient physical therapy or speech pathology

services, or a community mental health center that has in effect a similar

agreement but only to furnish partial hospitalization or intensive outpatient

services).

Home Health Change of Care Notice (HHCCN, Form CMS-10280) - Used

by Home Health Agencies (HHAs) to notify Original Medicare beneficiaries

receiving home health care benefits of plan of care changes. HHAs are

required to provide notification to beneficiaries before reducing or terminating

an item and/or service.

Hospital-Issued Notices of Non -coverage (HINNs) - Hospitals provide to

beneficiaries prior to admission, at admission, or at any point during an

inpatient stay if the hospital determines that the care the beneficiary is

receiving, or is about to receive, is not covered by Medicare.

Important Message from Medicare (IM, Form CMS-R-193) – Hospital

Discharge Appeal Notice delivered to all Medicare beneficiaries (Original

Medicare beneficiaries and Medicare Advantage plan enrollees) who are

hospital inpatients. The IM informs hospitalized inpatient beneficiaries of

their hospital discharge appeal rights.

Limitation on Liability (LOL) Provision– The LOL provisions, §1879(a)-(g)

of the Social Security Act, fall under the FLP provisions and provide financial

relief and protection to beneficiaries, healthcare providers, and suppliers by

permitting Medicare payment to be made, or requiring refunds to be made, for

certain items and/or services for which Medicare payment would otherwise be

denied.

Limitation on Recoupment – The requirement that (in certain cases)

Medicare must cease or delay recovery of an overpayment when a valid first

or second level appeal request is received from a provider on an overpayment,

in accordance with Section 1893 of the Social Security Act. For more

information, see 100-06 Medicare Financial Management Manual, Chapter 3,

Overpayments.

Medicare Beneficiary Identifier (MBI) - is a general term describing a

beneficiary's

Medicare identification number. Medicare beneficiary identifier references

both the Health Insurance Claim Number (HICN) and the Medicare

Beneficiary Identifier (MBI) during the new Medicare card transition period

and after for certain business areas that will continue to use the HICN as part

of their processes.

Medicare Contractor - An entity that contracts with the Federal government

to review and/or adjudicate claims, determinations and/or decisions.

Medicare Outpatient Observation Notice (MOON, Form CMS-10611) - A

standardized notice to inform Medicare beneficiaries (including health plan

enrollees) that they are outpatients receiving observation services and are not

inpatients of a hospital or CAH.

Notice of Medicare Non-Coverage (NOMNC, Form CMS-10123) - FFS

Expedited Determination Notices that informs beneficiaries on how to request

an expedited determination from their Quality Improvement Organization

(QIO) and gives beneficiaries the opportunity to request an expedited

determination from a QIO.

Overpayment Recovery Waiver – An allowance providing that beneficiaries,

healthcare providers, and suppliers can keep Medicare overpayments (in

certain circumstances) if they are determined to be “without fault” for causing

the overpayment, in accordance with Section 1870 of the Social Security Act.

For more information, see 100-06 Medicare Financial Management Manual,

Chapter 3, Overpayments.

Refund Requirements (RR) for Non-assigned Claims for Physicians

Services - Under §9332(c) of OBRA 1986 (P.L. 99-509), which added

§1842(l) to the Social Security Act, new liability protections for Medicare

beneficiaries affect nonparticipating physicians.

Refund Requirements (RR) for Assigned and Non-assigned Claims for

Medical

Equipment and Supplies – Under §132 of SSAA-1994 (Social Security Act

Amendments of 1994, P.L. 103-432) which adds §1834(a)(18) to the Social

Security Act, and under §133 of SSAA-1994 which adds §1834(j)(4) and

§1879(h) to the Social Security Act, new liability protections for Medicare

beneficiaries affect suppliers of medical equipment and supplies. All suppliers

who sell or rent medical equipment and supplies to Medicare beneficiaries are

subject to the refund provisions of §§1834(a)(18), 1834(j)(4) and 1879(h) of

the Social Security Act.

Skilled Nursing Facility Advance Notice of Non-coverage (SNF ABN, Form

CMS-

10055) – Issued in order for a Skilled Nursing Facility (SNF) to transfer

financial liability to an Original Medicare beneficiary for items or services,

paid under the SNF PPS, that Medicare is expected to deny payment (entirely

or in part).

Supplier – Unless the context otherwise requires, a physician or other

practitioner, a facility, or entity (other than a provider of services) that furnishes

health services covered by Medicare.