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Beneficiary Notices Initiative (BNI)

    Current News
    Earlier this year, it was announced that the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) would be finalized October 1, 2004. However, the evaluation of the SNFABN, as well as the evaluation of the Notice of Exclusions from Medicare Benefits- Skilled Nursing Facility (NEMB-SNF) is ongoing. At this time, the completion date for the evaluation of both notices is not known. Use of the SNFABN and the NEMB-SNF continues to be voluntary. We will up-date this webpage as more information becomes available.

Go to FFS FLP Notices   Medicare Advantage Notices    Privacy Notices

BNI OVERVIEW

OBJECTIVE: It is an agency objective to improve agency-to-beneficiary communications in order to further beneficiary education and health promotion, and to facilitate access to and exercise of individual rights and protections. The use of beneficiary notices is one of CMS' best opportunities to achieve successful outreach to program beneficiaries. CMS directly touches the lives of millions of beneficiaries every day by its program notices to beneficiaries.

PURPOSE: The purpose of the CMS Beneficiary Notices Initiative [BNI] is to wed consumer rights and protections with effective beneficiary communication so that beneficiaries are given the opportunity to timely exercise their rights and protections in a well-informed manner. These rights and protections are both statutorily & regulatorily mandated, as well as by Executive Order, and are enunciated in various venues and formats, such as providers' Conditions of Participation, the President's Consumer Bill of Rights & Responsibilities, Privacy Act Statements, and statements of non-discrimination (the Civil Rights Act).

FEATURES:

BNI - improving notices to improve beneficiary communications:

  • by furthering beneficiary education and health promotion
  • by facilitating access to and exercise of individual rights and protections (notices are given to beneficiaries every day, in all physician, supplier, provider, and health plan settings)
  • Since 1999, the agency, through its Beneficiary Notices Initiative, has been:
    • formulating organizing principles and coherent communication plan strategy
    • systematically revisiting and, as necessary, revising beneficiary notices

Through the BNI, CMS can:

  • change the way it interacts with beneficiaries about rights and protections
  • model the behavior of a prudent purchaser in today's health care market by drafting notices that go beyond simply complying with legal requirements

CMS has the opportunity to better serve its beneficiaries by:

  • accurately informing beneficiaries as to viable choices
  • providing the information necessary to exercise rights and protections
  • encouraging the exercise of individual responsibilities, including becoming pro-active partners in one's own health care decisions and combating fraud and abuse

Replicable Adobe Acrobat PDF files are furnished. Viewing notices in the PDF format retains the appearance most accurately.


FFS FINANCIAL LIABILITY PROTECTIONS (FLP) NOTICES



Advance Beneficiary Notice [ABN], form CMS-R-131

The CMS-R-131 form is the ABN approved by OMB (Office of Management and Budget) on June 18, 2002. There are two CMS-R-131 forms, the General Use form ("ABN-G") and the Laboratory Tests form ("ABN-L"). Both CMS-R-131 ABN forms are standard forms which may not be modified.

  • CMS-R-131-G (General Use)
    English PDF file (106 K)
    Spanish PDF file (116 K)
  • CMS-R-131-L (Laboratory Tests)
    English PDF file (107 K)
    Spanish PDF file (118 K)
  • Instructions: Section 50 of Chapter 30 of the Medicare Claims Processing Manual (Pub. 100-4, PDF file 1.4 MB)
  • What Doctors Need to Know about the Advance Beneficiary Notice (ABN) [brochure]
    PDF file letter-size (6.88 MB, 01/13/2003)
    PDF file printer version (6.87 MB, 01/13/2003)

Notice of Exclusions from Medicare Benefits [NEMB], form CMS-20007

Notices of Exclusions from Medicare Benefits (NEMBs) may be used with items and services that are excluded from Medicare benefits. NEMBs alert Medicare beneficiaries in advance that Medicare does not cover certain items and services because they do not meet the definition of a Medicare benefit or because they are specifically excluded by law; that is, when the use of an ABN is not appropriate. There is an NEMB (i.e., form CMS-20007) for general use in any case and other NEMBs customized for certain items and services. (See the draft CMS-10111 NEMB-HHA and CMS-20014 NEMB-SNF, below.)

  • CMS-20007 (General Use)
    English PDF file (117 K)
    Spanish PDF file (117 K)
  • Instructions: Section 90 of Chapter 30 of the Medicare Claims Processing Manual (Pub. 100-4, PDF file 1.4 MB)
  • ADA NEMB (Dental Exclusions - American Dental Association)
    English PDF file (98 K)
  • APMA NEMB (Foot Care Exclusions - American Podiatric Medical Association)
    English PDF file (92 K)

Home Health Advance Beneficiary Notice [HHABN], form CMS-R-296

The CMS-R-296 form is the HHABN approved by OMB on June 4, 2002. The HCFA-R-296 (2-page form) is obsolete and may not be used.

  • CMS-R-296
    English PDF file(97 K)
    Spanish PDF file(99 K)
  • Instructions: Section 60 of Chapter 30 of the Medicare Claims Processing Manual (Pub. 100-4, PDF file 1.4 MB)

Notice of Exclusions from Medicare Benefits - Home Health Agency [NEMB-HHA], form CMS-10111

The draft model form Notice of Exclusions from Medicare Benefits - Home Health Agency (NEMB-HHA) may be used with home health items and services that are excluded from Medicare benefits. NEMB-HHAs alert Medicare beneficiaries in advance that Medicare does not cover certain items and services because they do not meet the definition of a Medicare benefit or because they are specifically excluded by law; that is, when the use of an HHABN is not appropriate. The model form CMS-10111 is presently in OMB clearance and is not now mandatory for use by HHAs.

  • CMS-10111
    English PDF file (413 K)
  • Draft Instructions PDF file (45 K): To be published in final in Section 60 of Chapter 30 of the Medicare Claims Processing Manual (Pub. 100-4, PDF file 1.4 MB)

Skilled Nursing Facility Advance Beneficiary Notice [SNFABN], model form CMS-10055

The model form CMS-10055 is a new SNFABN form for use by SNFs and should not be modified. SNFs may begin to use the new SNFABN form immediately. The SNFABN is not now mandatory for use by SNFs.

  • CMS-10055
    English PDF file (113 K)
  • Instructions: Section 70 of Chapter 30 of the Medicare Claims Processing Manual (Pub. 100-4, PDF file 1.4 MB)

Notice of Exclusions from Medicare Benefits - Skilled Nursing Facility [NEMB-SNF], form CMS-20014

The draft model form Notice of Exclusions from Medicare Benefits - Skilled Nursing Facility (NEMB-SNF) may be used with extended care items and services that are excluded from Medicare benefits. NEMB-SNFs alert Medicare beneficiaries in advance that Medicare does not cover certain extended care items and services because they do not meet the definition of a Medicare benefit or because they are specifically excluded by law; that is, when the use of an SNFABN is not appropriate. The model form CMS-20014 is presently in final development and is not now mandatory for use by SNFs.

  • CMS-20014
    English PDF file (458 K)
  • Draft Instructions PDF file (48 K): To be published in final in Section 70 of Chapter 30 of the Medicare Claims Processing Manual (Pub. 100-4, PDF file 1.4 MB)

Important Message from Medicare [IM], form CMS-R-193

The revised CMS-R-193 forms in English and Spanish were approved by OMB on January 22, 2003, and are standard forms that may not be modified. Hospitals are required to use only the new forms on and after August 1, 2003.


Hospital-Issued Notices of Noncoverage [HINNs]

The current model Hospital-Issued Notices of Noncoverage (HINNs) are published in the Medicare Claims Processing Manual (Pub. 100-4), Chapter 30, Section 130.9. Hospitals should use these forms to properly notify beneficiaries.

  • HINN Forms: Section 130.9 of Chapter 3 of the Medicare Claims Processing Manual (Pub. 100-4, PDF file 4 MB)
  • FLP Instructions: Section 80.2 of Chapter 30 of the Medicare Claims Processing Manual (Pub. 100-4, PDF file 1.4 MB)
  • Billing Instructions: Section 130 of Chapter 3 of the Medicare Claims Processing Manual (Pub. 100-4, PDF file 4 MB)
  • QIO Instructions: Chapter 7 of the Medicare Quality Improvement Organization Manual (Pub. 100-10, PDF file 1.2 MB)

FFS Financial Liability Protections Notices Exhibits

  • Law: §§ 1879; 1834(a)(18); 1834(j)(4); 1842(l); & 1862(a) PDF file (202 K)
  • Regulations: 42 CFR 411.400-408 PDF file (176 K)
  • Rulings: 95-1, 96-2, 96-3 and 97-1 PDF file (292 K)
  • Using the Modifiers Properly: Guidance on ABNs and the GA (PDF 19 K),   GZ (PDF 20 K),   GY (PDF 15 K)
  • Working Paper: Financial Liability Protection Provisions & Statutory FLP Triggers; Applicability of ABNs to Types of Claims Denials - ABN Matrix PDF file (231 K)
  • Informal Guidance for Ambulance Suppliers & Providers: "The Medicare Ambulance Benefit & Statutory Bases for Denial of Claims" and "Ambulance Transports & ABNs" PDF file (143 K)

MEDICARE ADVANTAGE NOTICES


Medicare Advantage [MA] Denial Notices, form CMS-10003

  • CMS-10003-NDP (Notice of Denial of Payment)
    PDF file (93 K)
  • CMS-10003-NDP Instructions
    PDF file (27 K)
  • CMS-10003-NDMC (Notice of Denial of Medical Coverage)
    PDF file (103 K)
  • CMS-10003-NDMC Instructions
    PDF file (24 K)

Medicare Advantage Expedited Notices, form CMS-10095

  • CMS-10095-A (Notice of Medicare Non-Coverage)
    PDF file (92 K)
  • Instructions PDF file (111 K)
  • CMS-10095-B (Detailed Explanation of Non-Coverage)
    PDF file (129 K)
  • Instructions PDF file (75 K)



PRIVACY NOTICES


OASIS Privacy Notices (Home Health Agency Outcome and Assessment Information Set)
See OASIS - Patient Privacy Notices for more information.



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Last Modified on Wednesday, October 06, 2004