CMS Pub. 100-04, ch. 30, § 70.6.1

Written Notification must be given by one of the following sources:

A. The SNF that is furnishing non-covered extended care items or services.

Examples:

• On or before the day of admission, the SNF furnishes to the beneficiary a SNF

ABN notifying the beneficiary that the extended care item(s) or service(s) is non-covered; or

• During the inpatient stay, the SNF timely furnishes to the beneficiary a SNF ABN

notifying the beneficiary that the covered extended care item(s) or service(s) will

no longer be covered.

B. The UR entity of the SNF that is furnishing non-covered extended care items or

services.

Example:

• The UR entity timely furnishes to the beneficiary a SNF ABN notifying the

beneficiary that the extended care item(s) or service(s) is no longer covered.

C. The QIO or Medicare contractor.

Example:

• The QIO, where a beneficiary is in a swing bed, timely furnishes to the

beneficiary, a SNF ABN notifying the beneficiary that the extended care item(s)

or service(s) is not covered or the item(s) or service(s) is no longer covered.

NOTE: This occurs after the beneficiary receives a HINN 1

(Preadmission/Admission HINN) and after the QIO’s decision of the non-coverage.

• The Medicare contractor sends the beneficiary her or his first notification of non-coverage (e.g., the MSN).