Policy Manual sample

MDT Home Health Care Agency, Inc. ABN ADDITIONAL DIRECTIONS 1. MD Order for discharge: The discharge narrative that states "MD notified and concurs'' is sufficient to meet ABN regulation. 2. Translation to Foreign Language: Clinician must document on ABN form how translation was done (i.e. through a family member, ATT, agency staff member, etc.) UP FROM PAYMENT FOR PATIENTS WHO CHECK "A" AND DO NOT HAVE SECONDARY INSURANCE 1. Forms should report total cost for 60 days of service including supplies. Clinician should seek assistance of manager/UR staff in calculating this. Public charges will be used. 2. Agency will expect up front “deposit” of cost for 30 days of service within 5 days of notice to patient from Patient Accounts. Failure of patient to make payment will result in termination of services. 3. In the situation when a patient checks 'A" and has no secondary insurance, clinicians need to call their manager form the patients home to notify them of the same. Manager needs to notify Patient Accounts that day. COMPLETING ABN FORM 1. ''Date of Notice"- Enter date you delivered the ABN form. If mailing form, enter date you notified beneficiary by telephone and date you mailed. 2. ''Beneficiary Name" - Enter name of beneficiary, do not enter representative's name. 3. ''Medicare # (HICN)'' - Enter health insurance claim number. 4. ''Attending physician'' - Enter ordering physician's name. 5. "Physician's telephone number"- Enter ordering physician's telephone number. 6. Check appropriate box for reason why you expect Medicare denial. Check the first box in the case of initiation of services; check second box for reduction of services; and check third box for termination of services. 7. In the paragraph entitled ''Why Medicare Won't Pay”, the second blank (We expect Medicare will not pay for ______), specify the particular services that the notice is being given for and the effective date (date services are scheduled to end or be reduced). Home Health Agency Policies A-127