Advance Beneficiary Notice of Non-coverage Tutorial Print

A. Notifier(s)

• You must place their name, address, and phone number (including TTY number, when needed) at the top of the notice. You may add this information to your logo at the top of the notice by typing, hand-writing, pre-printing, using a label, or other means.
• If you and the billing entity aren’t the same, you may list more than 1 entity in the Header if it’s specified in the Additional Information (H) section who we should contact with billing questions.

B. Patient Name

• You must enter the beneficiary’s first and last name and include a middle initial if it appears on their Medicare card. We won’t invalidate the ABN because of a misspelling or missing initial if the beneficiary or representative recognizes the name listed on the notice as the beneficiary’s.

C. Identification Number

• This field is optional. If there’s no identification number, it doesn’t invalidate the ABN. You may enter a beneficiary identification number that links the notice with a related claim, and you may create an internal filing number, like a medical record number. Don’t list Medicare Beneficiary Identifiers (MBIs) or SSNs on the notice.

First ABN D. Field

List 1 of these descriptors:

• Item
• Service
• Lab test
• Test
• Procedure
• Care
• Equipment

Second ABN D. Field

Use the same wording used in the first (D) field.

Third ABN D. Field

Use the same wording used in the first (D) field.

First D. Column

• The notifier must list the specific items or services they believe we won’t cover in the blank (D) column
• In a partial denial case, you must list the item’s or service’s excess component(s) for which denial is expected in the blank (D) column.
• Put general descriptions of specifically grouped supplies in this column. For example, wound care supplies is enough to describe an item group. We generally don’t require an itemized list of each supply.
• When you reduce a service, you must provide enough information so the beneficiary understands why. For example, we consider wound care supplies decreased from weekly to monthly enough to describe a frequency decrease for this supply category; just writing wound care supplies decreased isn’t enough.
• You must complete all 7 blank (D) fields to validate the notice. We encourage you to populate all blank (D) fields before using a general descriptor like Item(s) or Service(s).

E. Reason Medicare May Not Pay

In this column, notifiers must explain, in beneficiary friendly language, why they believe Medicare may not cover the items or services in column (D). Three non-coverage reasons we commonly use:

• We don’t pay for this test for your condition
• We don’t pay for this test this often (denied as too frequent)
• We don’t pay for experimental or research tests

To be a valid ABN, you must list at least 1 reason for each item or service in column (D). You can use the same non-coverage reason for multiple items in column (D) when appropriate.

F. Estimated Cost

• Notifiers must complete column (F) to ensure the beneficiary has all available information to decide whether to get potentially non-covered services.
• You must make a good faith effort to list a reasonable dollar estimate for all items or services in column (D). We expect the estimate be within $100 or 25% of actual costs, whichever is greater; generally, we accept estimates exceeding the actual cost, since it won’t harm the beneficiary if actual costs are less than predicted.
• Notifiers can bundle routinely grouped items or services into a single cost estimate. For example, you may give a single cost estimate for a group of lab tests like a Basic Metabolic Panel (BMP). We accept an average daily cost estimate for long-term or complex projections.
• You may also pre-print a menu of items or services in column (D) and include a cost estimate beside each item or service. If a situation calls for additional tests or procedures (such as lab reflex testing), and you can’t reasonably estimate those test costs at ABN delivery, you may enter the initial cost estimate and indicate possible further testing.
• If you can’t provide a good faith projected cost estimate at ABN delivery, you may indicate in the cost estimate area there’s no cost estimate available. You shouldn’t use these last 2 scenarios routinely or frequently, but the beneficiary has the option of signing the ABN and accepting liability in these situations.

G. Options

Complete the 3 (D) fields under the (G) Options section with the same wording used in the first (D) field. The beneficiary, or their representative, must choose 1 of the 3 options listed. We don’t allow you to make this selection.

Special guidance for people who are dually enrolled in both Medicare and Medicaid, also known as dually eligible individuals (has a Qualified Medicare Beneficiary [QMB] Program and or Medicaid coverage), ONLY:

Instruct them to check ABN Option Box 1 so the notifier can submit the claim for Medicare adjudication. Strike through Option Box 1 language as shown here:

□ OPTION 1. I want the D._______ listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN.

We require these edits because the notifier can’t bill the dually eligible beneficiary when they offer an ABN. You must not bill the beneficiary pending Medicare and Medicaid adjudication, because federal law affects dually eligible beneficiary coverage and billing.

If we deny a claim when you needed an ABN to transfer financial liability to the beneficiary, cross the claim over to Medicaid or submit it for adjudication based on state Medicaid coverage and payment policy. Medicaid will issue a Remittance Advice based on this determination. Once Medicare and Medicaid adjudicate the claim, you may only charge the patient in these circumstances:

• If the beneficiary has QMB coverage without full Medicaid coverage, the ABN could allow you to shift financial liability to the beneficiary per Medicare policy
• If the beneficiary has full Medicaid coverage and Medicaid denies the claim (or won’t pay because you don’t participate in Medicaid), the ABN could allow you to shift financial liability to the beneficiary per Medicare policy, subject to state laws that limit beneficiary liability

Note: The beneficiary doesn’t need to check an option box or sign and date the notice when you issue the ABN as a voluntary notice.

Option 1

The beneficiary wants to get the items or services listed and accepts financial responsibility if we don’t pay. They agree to pay now, if required. Notifiers must submit a claim to Medicare that results in a payment decision the beneficiary can appeal. If they need a Medicare claim denial for secondary insurance to cover the service, you may advise them to select Option 1.

Special guidance for non-participating suppliers and providers (those who don’t accept Medicare assignment) ONLY:

Strike the last Option Box 1 sentence as shown here:

□ OPTION 1. I want the D. ___________ listed above. You may ask for payment now, but I also want Medicare billed for an official decision on payment, sent to me, on a Medicare Summary Notice (MSN). I understand if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the MSN directions. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.

Notifiers, include this single line strike on ABNs printed specifically when you provide unassigned items and services. You can also hand-pen the line on an already-printed ABN. Don’t entirely conceal or delete the sentence. We don’t require you or beneficiaries to initial beside the sentence or date the annotations when you make the changes.

When you strike this sentence, you should include this CMS-approved unassigned claim statement in the (H) Additional Information section:

“This supplier doesn’t accept Medicare payment for the item(s) listed in the table above. If I checked Option 1 above, I am responsible for directly paying the supplier’s charge for the item(s). If Medicare does pay, Medicare will pay me the Medicare-approved amount for the item(s), and this payment may be less than the supplier’s charge.”

You can include this statement on ABNs printed for unassigned items and services, or hand-write it in a legible 10 point or larger font.

Fourth ABN D. Field

Use the same wording used in the first (D) field.

Fifth ABN D. Field

Use the same wording used in the first (D) field.

Sixth ABN D. Field

Use the same wording used in the first (D) field.

Option 2

The beneficiary wants to get the item or services listed and accepts financial responsibility. They agree to pay now, if required. When the beneficiary chooses this option, you don’t file a claim, and there are no appeal rights.

You won’t violate mandatory claims submission rules under section 1848 of the Social Security Act when you don’t submit a claim at the beneficiary’s written request.

Option 3

The beneficiary doesn’t want the care in question and you can’t charge them for items or services listed. You don’t file a claim, and there’s no appeal right.

H. Additional Information

Notifiers may use this space to clarify what they believe is useful to beneficiaries. You may use this space to include:

• Statement advising the beneficiary to notify their provider about certain ordered, but not received tests
• Information on other beneficiary insurance coverage, like a Medigap policy
• An additional dated witness signature
• Other necessary annotations

We assume notifiers made annotations on the same date that appears in field (J), accompanying the signature. If they made the annotations on different dates, make those dates part of the annotations.

I. Signature

The beneficiary (or representative) must sign the notice to indicate they got the notice and understand its contents. If a representative signs for a beneficiary, they should write out representative in parentheses after their signature. The representative’s name should be clearly legible or noted in print.

J. Date

The beneficiary (or representative) must write the date they signed the ABN. If the beneficiary has physical difficulty writing and requests assistance completing this field, the notifier may write the date.