Medicare ABN - Advance Beneficiary Notice of Noncoverage

The Use of an ABN in a Medical Office

Photo courtesy of cms.gov

An Advance Beneficiary Notice of Noncoverage (ABN) is a notice Medicare requires health care providers issue to Medicare patients to alert them that Medicare may not pay for certain services or tests prior to having them performed in an outpatient setting. This allows the patient to make an informed decision about whether they want to receive the services and accept full financial responsibility if Medicare does not pay.

An ABN is not required for items or services that Medicare never covers. For example, dentures, acupuncture, cosmetic surgery, hearing aids, and routine foot care do not require an ABN because they are not covered under Medicare Part A and Part B.

Form CMS-R-131 to use for fee for service ABN is available from the CMS.gov website in English and Spanish.

Providers Must Issue an ABN or They Cannot Bill for the Noncovered Service

According to Medicare guidelines, a provider must provide the Medicare patient an ABN or they cannot bill the patient for the noncovered service. When an ABN is issued and signed by the patient, the provider can freely bill the patient for the noncovered charges. When an ABN is not issued, the provider may not bill the noncovered services to the patient.

Reasons Medicare May Deny an Item or Service Usually Covered

Providers must issue an ABN when they believe Medicare may not pay for the item or service that is usually covered by Medicare.

The general reason is that it is not medically reasonable and necessary, including investigational items, those not considered safe or effective, those not indicated for the patient's diagnosis, or when the number of services exceeds those allowed by Medicare in a specific time period for the patient's diagnosis.

Medical equipment and supplies might be denied because the supplier has no supplier number or they made an unsolicited telephone contact.

Completing an ABN

There are mandatory fields that must be filled out on an ABN for it to be considered valid. The form should only be one page long and printed in large enough type and printed with enough contrast to be easily read. The forms from CMS.gov can be customized to some extent. An electronic ABN can be signed, but a paper version must be provided upon request. The ABN can be provided via email, mail, or secure fax as long as it follows HIPAA policy. The signed ABN should be kept for five years from the date of care, including those where the patient refused to sign or declined care.

A. Health care provider's name, address and telephone number

B. The patient name

C. Identification Number

D. Description of the services that are believed to be noncovered

E. Reason that the services may not be covered by Medicare

F. The estimated cost of the services

G. Three option boxes, the patient must choose only one.

  • Option 1 indicates the patient wants the service or item and may be asked to pay now, but they want Medicare to be billed so there is an official decision and they could make an appeal to Medicare.
  • Option 2 indicates the patient wants the service or item, will be responsible for the payment, and Medicare will not be billed.
  • Option 3 indicates the patient chooses not to receive the service or item and understands they cannot appeal to see if Medicare will pay

H. Additional Information (not required)

I. Signature of patient or patient representative

J. Date

What If the Patient Refuses to Sign the ABN?

If a patient refuses to sign the ABN, make sure to document the ABN with this information. Unless the service is critical to the health and safety of the patient, it may be a good idea not to perform the service.

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