CMS Pub. 100-04, ch. 30, § 70.5

A. Collection from Beneficiary

When a SNF ABN is properly executed and given timely to a beneficiary and Medicare

denies payment on the related claim, the SNF must wait for the beneficiary to receive a

Medicare Summary Notice (MSN) before it can collect payment on the related claim.

Medicare does not limit the amount that the SNF may collect from the beneficiary in such

a situation. A beneficiary’s agreement to “be personally and fully responsible for

payment” means that the beneficiary agrees to pay out of pocket or through any other

insurance that the beneficiary may have, e.g., through employer group health plan

coverage, through Medicaid, or through some other Federal or non-Federal payment

source.

NOTE: The beneficiary may request a demand bill at any point in her or his care.

B. Unbundling Prohibition

The SNF ABNs may not be used to shift financial liability to a beneficiary in the case of

services for which full payment is bundled into other payments; that is, where the

beneficiary would otherwise not be financially liable for payment for an extended care

item or service because Medicare made a bundled payment. Using a SNF ABN to collect

from a beneficiary where full payment is made on a bundled basis would constitute

double billing. A SNF ABN may be used to shift financial liability to a beneficiary in the

case of extended care items or services for which partial payment is bundled into other

payments; that is, where part of the cost is not included in the bundled payment made by

Medicare.

C. Acceptance or Rejection of SNF ABN

These instructions are to assist the Medicare contractor in advising SNFs with respect to

their responsibilities in advising beneficiaries with respect to their rights and protections

and in dealing with complaints from beneficiaries, or authorized representatives, about

the lack of notice or defective notice. The SNF should:

• Answer inquiries from a beneficiary regarding the basis for the SNF’s, the UR

entity’s, the QIO’s, or the Medicare contractor’s assessment that extended care

items or services may not be covered and, if requested by the beneficiary, the SNF

must give the beneficiary access to medical record information or other

documents upon which these entities based their assessment, to the extent

permissible or required under applicable state law.

NOTE: Where state law prohibits such direct disclosure, the SNF should advise

a beneficiary who has requested access to such information how to obtain that

information from the SNF once a demand bill has been submitted.

• Respond timely, accurately, and completely to a beneficiary who requests

information about the extent of the beneficiary’s personal financial liability.

• Timely submit additional information to the Medicare contractor, if a beneficiary

or a physician provides that additional information with respect to Medicare

coverage of the subject extended care items or services.