- Section 1 Introduction
- Introduction
- Federal Government Administration
- Fundamentals of Medicare: State Responsibilities
- Fundamentals of Medicare: Participating Providers
- Voluntary and Involuntary Termination of Provider Agreement
- Disclosure of Health Insurance Information
- Privacy Act
- National Provider Identifier
- Legacy Provider Numbers/Provider Transaction Access Numbers (PTANs)
- Medicare Administrative Contractors
- Fundamentals of Medicare: Information References
- Acronyms
- Fundamentals of Medicare: Glossary of Terms
- Section 2 Medicare Basics
- The History of Medicare
- What Is the Medicare Program and How Is It Funded?
- Medicare Eligibility and Premiums
- The Social Security Administration and Medicare Enrollment
- The Medicare Card
- Medicare Part A
- Inpatient Hospital Care
- Skilled Nursing Facility Inpatient Care
- Home Health Care Benefit
- The Hospice Benefit
- Medicare Part B Medical Insurance
- Fundamentals of Medicare - Medicare Program Exclusions
- Medicare Advantage Organizations
- Medicare Secondary Payer
- Supplemental Insurance
- Coordination of Benefits Trading Partners
- Section 3 Fraud and Abuse
- Section 4 Getting Ready to Bill Medicare
Section 4: Getting Ready to Bill Medicare
Advance Beneficiary Notice of Noncoverage
An ABN is a written notice a provider gives to a Medicare beneficiary before items or services are furnished, when the provider believes that Medicare probably or certainly will not pay for some or all of the items/services on the basis of one of the following statutory exclusions:
- Section 1862(a)(1) of the Social Security Act (the Act), for example:
- medical reasonableness and necessity
- custodial care
- mammography
- pap smear
- pelvic exam
- glaucoma
- prostate cancer, and
- colorectal cancer screening tests
- Section 1834(a)(17)(B) of the Act, violation of the prohibition on unsolicited telephone contacts for medical equipment and supplies
- Section 1834(j)(1) of the Act, medical equipment and supplies supplier number requirements not met, and
- Section 1834(a) (15) of the Act, medical equipment and/or supplies is denied in advance
The only other applicable bases of denial for which ABNs are applicable, i.e.:
- Section 1862(a)(9) of the Act, custodial care
- Section 1879(g)(1) of the Act, homebound and intermittent denials for home health care, and
- Section 1879(g)(2) of the Act, hospice patient is not terminally ill, are unlikely to apply in a Part B situation
ABNs are designed for use with Medicare beneficiaries only, including those who are dually eligible for Medicare and Medicaid. ABNs are not for use with patients who are not Medicare beneficiaries. The purpose of the ABN is to inform a Medicare beneficiary, before he or she receives specified items or services that otherwise might be paid for, that Medicare probably will not pay for them on that particular occasion.
The ABN also allows the beneficiary to make an informed consumer-decision whether or not to receive the items or services for which he or she may have to pay out-of-pocket or through other insurance.
In addition, the ABN allows the beneficiary to better participate in his/her own health care treatment decisions by making informed consumer decisions. If the provider expects payment for the items or services to be denied by Medicare, the provider must advise the beneficiary before items or services are furnished that in their opinion the beneficiary will be personally and fully responsible for payment.This means the beneficiary will be liable to make payment “out-of-pocket,” through other insurance coverage (e.g., employer group health plan coverage), or through Medicaid or other Federal or nonfederal payment source.
The provider must issue notices each time, and as soon as, they make the assessment that Medicare payment probably or certainly will not be made. If a provider fails to provide a proper ABN in situations where one is required, the provider may be liable under the provisions of Limitation of Liability (LOL) or Refund Requirements (RR), where such provisions apply, unless the provider can show that they did not know and could not reasonably have been expected to know that Medicare would deny payment. To be acceptable, an ABN must be on the approved CMS Form CMS-R-131, must clearly identify the particular item or service, must state that the provider believes Medicare is likely (or certain) to deny payment for the particular item or service, and must give the provider’s reason(s) for their belief that Medicare is likely (or certain) to deny payment for the item or service. Additional information on ABNs can be found in the CMS Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 30.
Revised 1/2021