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Advance Beneficiary Notice of Noncoverage (ABN) Form Instructions Tool

NOTIFIER

A. Notifier(s)

  • Notifiers must place their name, address, and telephone number (including TTY number when needed) at the top of the notice. This information may be incorporated into a notifier’s logo at the top of the notice by typing, hand-writing, pre-printing, using a label or other means.
  • If the billing and notifying entities are not the same, the name of more than one entity may be given in the Header as long as it is specified in the Additional Information (H) section who should be contacted for billing questions.
PATIENT NAME

B. Patient Name

  • Notifiers must enter the first and last name of the beneficiary receiving the notice, and a middle initial should also be used if there is one on the beneficiary’s Medicare card. The ABN will not be invalidated by a misspelling or missing initial, as long as the beneficiary or representative recognizes the name listed on the notice as that of the beneficiary.
IDENTIFICATION NUMBER

C. Identification Number

  • Use of this field is optional. Notifiers may enter an identification number for the beneficiary that helps to link the notice with a related claim. The absence of an identification number does not invalidate the ABN. An internal filing number created by the notifier, such as a medical record number, may be used. Medicare numbers or Social Security numbers must not appear on the notice.
First D. field in ABN

First D. field in ABN

The following descriptors may be used in the first D. field:

  • Item
  • Service
  • Laboratory test
  • Test
  • Procedure
  • Care
  • Equipment
Second D. field in ABN

Second D. field in ABN

  • Insert the wording used in the first D. field.
First column in Table D

First column in Table D

  • The notifier must list the specific names of the items or services believed to be noncovered in the column directly under the header of Blank D.
  • In the case of partial denials, notifiers must list in the column under Blank D. the excess component(s) of the item or service for which denial is expected.
  • For repetitive or continuous noncovered care, notifiers must specify the frequency and/or duration of the item or service. See Medicare Claims Processing Manual, Chapter 30, Section 50.7.1External PDF for additional information.
  • General descriptions of specifically grouped supplies are permitted in this column. For example, “wound care supplies” would be a sufficient description of a group of items used to provide this care. An itemized list of each supply is generally not required.
  • When a reduction in service occurs, notifiers must provide enough additional information so that the beneficiary understands the nature of the reduction. For example, entering “wound care supplies decreased from weekly to monthly” would be appropriate to describe a decrease in frequency for this category of supplies; just writing “wound care supplies decreased” is insufficient.
  • Please note that there are a total of 7 Blank D. fields that the notifier must complete on the ABN. Notifiers are encouraged to populate all of the Blank D. fields in advance when a general descriptor such as “Item(s)/Service(s)” is used. All Blank D. fields must be completed on the ABN in order for the notice to be considered valid.
E. Reason Medicare May Not Pay

E. Reason Medicare May Not Pay

In the column under this header, notifiers must explain, in beneficiary friendly language, why they believe the items or services listed in the column under Blank D. may not be covered by Medicare. Three commonly used reasons for noncoverage are:

  • “Medicare does not pay for this test for your condition.”
  • “Medicare does not pay for this test as often as this (denied as too frequent).”
  • “Medicare does not pay for experimental or research use tests.”

To be a valid ABN, there must be at least one reason applicable to each item or service listed in the column under blank D. The same reason for noncoverage may be applied to multiple items in Blank D. when appropriate.

F. Estimated Cost

F. Estimated Cost

  • Notifiers must complete the column under Blank F. to ensure the beneficiary has all available information to make an informed decision about whether or not to obtain potentially noncovered services.
  • Notifiers must make a good faith effort to insert a reasonable estimate for all of the items or services listed under Blank D. In general, we would expect that the estimate should be within $100 or 25% of the actual costs, whichever is greater; however, an estimate that exceeds the actual cost substantially would generally still be acceptable, since the beneficiary would not be harmed if the actual costs were less than predicted. Thus, examples of acceptable estimates would include, but not be limited to, the following:
  • For a service that costs $250:
    • Any dollar estimate equal to or greater than $150
    • Between $150–300
    • No more than $500
  • For a service that costs $500:
    • Any dollar estimate equal to or greater than $375
    • Between $400–600
    • No more than $700

Multiple items or services that are routinely grouped can be bundled into a single cost estimate.

Field D. under “What You Need To Do Now”

Field D. under “What You Need To Do Now”

  • Insert the wording used in the first D. field.
OPTION 1

Option 1

The beneficiary wants to get the items or services listed and accepts financial responsibility if Medicare does not pay. He or she agrees to pay now, if required.

You must submit a claim to Medicare that will result in a payment decision the beneficiary can appeal. If the beneficiary needs a Medicare claim denial for a secondary insurance plan to cover the service, you may advise the beneficiary to select Option 1.

Field D. under G. Options

Field D. under G. Options

  • Insert the wording used in the first D. field.
OPTION 2

Option 2

The beneficiary wants to get the item or services listed and accepts financial responsibility. He or she agrees to pay now, if required. When the beneficiary chooses this option, you do not file a claim, and there are no appeal rights.

You will not violate mandatory claims submission rules under Section 1848 of the Social Security Act when you do not submit a claim to Medicare at the beneficiary’s written request.

Field D. under G. Options

Field D. under G. Options

  • Insert the wording used in the first D. field.
Option 3

Option 3

The beneficiary does not want the care in question and cannot be charged for any items or services listed. You do not file a claim, and there are no appeal rights.

Field D. under G. Options

Field D. under G. Options

  • Insert the wording used in the first D. field.
Additional Information

H. Additional Information

Notifiers may use this space to provide additional clarification that they believe will be of use to beneficiaries. For example, notifiers may use this space to include:

  • A statement advising the beneficiary to notify his or her provider about certain tests that were ordered, but not received
  • Information on other insurance coverage for beneficiaries, such as a Medigap policy, if applicable
  • An additional dated witness signature
  • Other necessary annotations

Annotations will be assumed to have been made on the same date as that appearing in Blank J, accompanying the signature. If annotations are made on different dates, those dates should be part of the annotations.

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

Strike the last sentence in the Option 1 paragraph with a single line so that it appears like this: If Medicare does pay, you will refund any payments I made to you, less co- pays or deductibles.

This single line strike can be included on ABNs printed specifically for issuance when unassigned items and services are furnished. Alternatively, the line can be hand-penned on an already printed ABN.

The sentence must be stricken and can’t be entirely concealed or deleted.

There is no CMS requirement for suppliers or the beneficiary to place initials next to the stricken sentence or date the annotations when the notifier makes the changes to the ABN before issuing the notice to the beneficiary.

When this sentence is stricken, the supplier shall include the following CMS-approved unassigned claim statement in the (H) Additional Information section.

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

  • This statement can be included on ABNs printed for unassigned items and services, or it can be handwritten in a legible 10 point or larger font.
  • An ABN with the Option 1 sentence stricken must contain the CMS-approved unassigned claim statement as written above to be considered valid notice. Similarly, when the unassigned claim statement is included in the “Additional Information” section, the last sentence in Option 1 should be stricken
SIGNATURE

I. Signature

The beneficiary (or representative) must sign the notice to indicate that he or she received the notice and understands its contents. If a representative signs on behalf of a beneficiary, he or she should write out “representative” in parentheses after his or her signature. The representative’s name should be clearly legible or noted in print.

DATE

J. Date

The beneficiary (or representative) must write the date he or she signed the ABN. If the beneficiary has physical difficulty with writing and requests assistance in completing this blank, the date may be inserted by the notifier.

The ABN form, completion instructions, and manual instructions are located on the CMS WebsiteExternal Website

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