Skilled nursing facilities use two main written notices to tell Medicare residents that payment may stop: the Advance Beneficiary Notice of Noncoverage (ABN) for Part B services the facility thinks Medicare will deny, and the Notice of Medicare Non-Coverage (NOMNC) when the entire covered stay is ending. A third form, the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), does the same job as the ABN but for Part A. Each notice starts a different clock and carries different appeal rights, and the wrong response, or no response, can shift thousands of dollars in facility costs onto you.
What Each Notice Actually Does
The three forms look similar on paper and get handed out in similar circumstances, but they answer different questions.
The SNFABN (Form CMS-10055) is the notice that matters most during a covered Part A stay. The facility issues it when it believes Medicare Part A will no longer pay for your skilled nursing or therapy, usually because the care has become custodial or you’ve stopped showing measurable improvement.1Centers for Medicare & Medicaid Services. Form Instructions: Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) Custodial care means help with daily activities like bathing, dressing, and eating, rather than treatment that requires trained nursing or therapy staff. The facility must give you the SNFABN before the service in question is provided. If it doesn’t, it can’t bill you when Medicare denies payment.
The ABN (Form CMS-R-131) does the same thing for Part B: a specific therapy session, a piece of durable medical equipment, or a diagnostic test the facility expects Medicare to deny.2Centers for Medicare & Medicaid Services. FFS ABN You should receive it before the new service starts or before an ongoing Part B service is reduced. The form has to describe each item at issue and give a good-faith cost estimate.3Centers for Medicare & Medicaid Services. ABN Form Instructions Same liability rule: no valid ABN, no bill to you.
The NOMNC (Form CMS-10123) is different in kind. It doesn’t flag one service. It tells you the whole Medicare-covered episode is ending on a specific date because the facility has decided you no longer meet the clinical criteria for skilled care.4Centers for Medicare & Medicaid Services. Notice of Medicare Provider Non-Coverage – CMS-10123 Instructions Federal rules require delivery at least two calendar days before that date.5eCFR. 42 CFR 405.1200 – Notifying Beneficiaries of Provider Service Terminations Once the date passes, you’re personally responsible for the full daily rate, which runs a national median of roughly $314 per day for a semi-private room and $361 for a private room.
Put simply: an ABN or SNFABN is about one service. A NOMNC is about everything.
If You Get an ABN or SNFABN: Pick the Right Option
The ABN has three checkboxes, and the choice matters:3Centers for Medicare & Medicaid Services. ABN Form Instructions
- Option 1. You want the service and want Medicare billed. If Medicare denies, you pay, but you can appeal the denial. If Medicare pays, any amount you already paid (minus copays and deductibles) is refunded.
- Option 2. You want the service but do not want Medicare billed. You pay out of pocket immediately and give up appeal rights, because no claim is filed for Medicare to review.
- Option 3. You don’t want the service. You owe nothing, and there’s nothing to appeal.
Option 1 is almost always the right choice if you want the care, because it preserves your right to a formal Medicare decision. Option 2 only makes sense in unusual situations where you specifically want to avoid a Medicare claim on record. Signing the form without checking a box defaults to Option 1.
Check the paperwork before you sign. The form has to describe the service, give a cost estimate, and reach you before the service is provided. A notice that’s late, vague, or missing the estimate may not be valid, and an invalid notice means the facility can’t shift the bill to you. If something looks incomplete, ask the billing office to explain, and contact your State Long-Term Care Ombudsman if you don’t get a straight answer.
If You Get a NOMNC: The Clock Starts Now
The single most important deadline in this whole process is noon on the calendar day after you receive the NOMNC. Before that cutoff, call the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) listed on your notice and request an expedited determination.6Centers for Medicare & Medicaid Services. Expedited Determination (ED) Process for Original Medicare Miss it and you don’t lose your appeal rights entirely, but you lose the financial protection that makes the fast-track process worth using.
Once the QIO has your request, it notifies the facility, which must hand over your medical records and a clinical explanation of why coverage should end.7eCFR. 42 CFR 405.1202 – Expedited Determination Procedures The QIO takes your side of the story too and asks the facility’s physician to explain the discharge decision. It’s an independent review, not a rubber stamp.
The QIO has to decide within 72 hours of your request.7eCFR. 42 CFR 405.1202 – Expedited Determination Procedures While that review is running, the facility generally can’t discharge you or stop the services in question. If the QIO rules for you, Medicare keeps paying and the facility keeps providing care. If the QIO sides with the facility, you become financially liable starting at noon on the calendar day after you receive the decision.
The Detailed Explanation of Non-Coverage
When you file, the facility also has to prepare a Detailed Explanation of Non-Coverage (DENC), Form CMS-10124, due by the close of business the day the QIO tells the facility you’ve appealed.8Centers for Medicare & Medicaid Services. Detailed Explanation of Non-Coverage Instructions The DENC has to give patient-specific clinical facts, a plain-English explanation of why services are ending, and the specific Medicare guidelines that support the decision. A vague or unsupported DENC can push the QIO to rule against the facility, and the facility can be held liable for the continued care.7eCFR. 42 CFR 405.1202 – Expedited Determination Procedures Ask for a copy of your DENC; it tells you exactly what argument you’re up against.
Medicare Advantage: Same Form, Different Follow-Up
If you’re on a Medicare Advantage plan, you get the same NOMNC and the same two-day advance rule.9Centers for Medicare & Medicaid Services. Notices and Forms The fast-track appeal still goes through the BFCC-QIO. If you miss the QIO deadline, you can still ask your plan directly for a fast reconsideration, but services will only stay covered if the decision comes back in your favor.10Medicare.gov. Fast Appeals Confirm with your plan which QIO covers your region.
If the QIO Denies Your Appeal
A QIO loss isn’t the end. You can ask the Qualified Independent Contractor (QIC) for a reconsideration by noon of the day after the QIO decision. The QIC runs its own review and usually issues a decision within 72 hours. The facility can’t bill you while that review is pending, but if the QIC also rules against you, you owe for the services provided during the deliberation period as well.
Miss the QIC deadline and you still have up to 180 days to file a standard (non-expedited) appeal, but you lose the financial protection during the review. The standard process takes up to 60 days and you’ll owe for services rendered in the meantime. Beyond the QIC, the process continues through an Administrative Law Judge hearing, the Departmental Appeals Board, and federal court, each with its own deadlines and, at the higher levels, minimum dollar thresholds.
The Demand Bill: A Second Path When You Disagree
Many families never hear about this one. If the facility tells you Medicare won’t cover your continued stay and you disagree, you can ask the facility to submit the claim to Medicare anyway. This is a demand bill, filed with condition code 20, which sends it for medical review.
While Medicare reviews the demand bill, the facility can’t bill you. Medicare will request the facility’s records and a copy of the signed notice, then issue a formal determination. If Medicare denies, you can move into the standard five-level appeal. The demand bill is especially useful when you’ve been handed an SNFABN saying Part A won’t cover your stay but you believe you still need skilled care. It forces Medicare, not the facility, to put the decision in writing.
Losing Coverage Is Not the Same as Being Discharged
Medicare stopping payment doesn’t mean the facility can make you leave. Federal rules require at least 30 days’ written advance notice before any involuntary transfer or discharge, whatever your insurance status, with a copy to the State Long-Term Care Ombudsman.11eCFR. 42 CFR Part 483 Subpart B – Requirements for Long Term Care Facilities Involuntary discharge is limited to a short list of reasons: the facility can’t meet your care needs, your health has improved enough that nursing home care isn’t needed, you endanger others, you haven’t paid, or the facility is closing. A facility can’t discharge you simply because Medicare stopped paying, as long as you’re willing and able to pay through Medicaid, private funds, or long-term care insurance.
The ombudsman program is free and investigates complaints on behalf of nursing home residents. If a facility is pressuring you to leave without proper notice or a valid reason, call the Eldercare Locator at 1-800-677-1116 for your state’s ombudsman.
Mistakes That Cost Families Money
The biggest one is doing nothing. Every notice here comes with appeal rights, and the deadlines are measured in hours. Noon the next day arrives fast when someone in the family is also managing a medical crisis.
Second: confusing the notices. An ABN or SNFABN about one service doesn’t touch your other covered care. A NOMNC ends everything. An ABN calls for careful selection among the three options; a NOMNC calls for a same-day decision about the fast-track appeal.
Third: not reading the paperwork. A notice missing the cost estimate, arriving late, or lacking the required clinical explanation may not be valid, and an invalid notice means the facility can’t shift the bill to you. If it looks incomplete, ask, and if the answer isn’t clear, call the ombudsman.