Advance Beneficiary Notice
An Advance Beneficiary Notice (ABN) is a notice to beneficiaries in traditional Medicare explaining that Medicare is not likely to cover a specific service. The ABN may be given by physicians or providers of outpatient services. The ABN must be delivered to beneficiaries in advance of receiving the item or service to allow the beneficiary time to consider if he or she wants the service. The beneficiary will have the opportunity to ask questions. The ABN will explain the reason payment by Medicare isn’t expected and outline the estimated cost to the beneficiary if he/she decides to receive the item/service. Common reasons Medicare will deny payment include:
- Medicare doesn’t consider the item or service medically necessary
- The item or service has been provided in excess of frequency limits
- The item or service is experimental.
In order for the ABN to be valid, it must be fully completed. The beneficiary then must indicate his/her choice. The options include:
- The beneficiary may choose to sign the ABN, agreeing to pay for the service. The beneficiary requests that the provider bill Medicare, and has a right to appeal Medicare’s decision. The beneficiary is responsible for payment if Medicare doesn’t pay for the service or item.
- The beneficiary may sign the ABN, agreeing to pay for the service. The beneficiary understands he/she is responsible for payment. The provider doesn’t bill Medicare and the beneficiary doesn’t have the right to appeal Medicare’s decision.
- The beneficiary may sign the ABN indicating he/she has declined the service. The beneficiary cannot appeal the decision in order to determine if Medicare would have paid.
Other things to consider:
- Blank or partially completed ABNs are not valid. All sections must be completed before the beneficiary signs the notice.
- The beneficiary’s Medicare identification number or social security number may not appear on the ABN.
- General descriptions of specifically grouped supplies are permitted. For example, “wound care supplies” would be a sufficient description.
- There must be at least one reason applicable to each item or service as to why the provider believes the item or service isn’t covered.
- ABN’s are never required in an emergency or urgent care situation.
- Blanket or routine ABNs aren’t valid. ABNs may not be given to beneficiaries when there is no specific, identifiable reason to believe Medicare will not pay. Giving routine notices for all claims or services is not an acceptable practice.
- Generic ABNs that state only that Medicare denial of payment is possible, or that the provider never knows whether Medicare will deny payment, aren’t valid. The ABN must specify the item or service and a genuine reason why the provider expects Medicare to deny payment.
- If the beneficiary is unable to understand the notice, a representative of the patient may be asked to sign the notice. The representative should sign his/her own name and write “representative” in parentheses after his/her signature.
For additional information, please review the Centers for Medicare and Medicaid Services (CMS) website at http://www.cms.hhs.gov/BNI.
Page last updated on Jul. 06, 2009