Advance Beneficiary Notice (ABN)

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Form CMS-R-131 or Advance Beneficiary Notice (ABN) is a written notice that is given to Medicare beneficiaries when item(s) or service(s) is/are expected to not get paid for certain reasons, such as lack of medical necessity.  Providers (including independent laboratories, physicians, practitioners and suppliers) are required to give a beneficiary this notice when payment is expected to be denied by Medicare.

 

The ABN allows the patient to make an informed decision and accept financial responsibility.  Providers should be aware that if the beneficiary does not receive this notice, he/she may not be held financially responsible if Medicare denies payment.  Thus, it is essential for providers to provide these forms to applicable patients.

The ABN must have the following information:

  1. Specific names of the items or services believed to be non-covered.
  2. An explanation of why the provider believes that the item(s) or service(s) that is/are listed may not be covered by Medicare.
  3. The estimated cost also must be listed because this is a necessary component for the patient to make an informed decision. In general, it is expected that the estimate given is within $100.00 or 25% of the actual costs, whichever is greater.
  4. Selected option by the patient.  The patient has 3 options to select from:
    • The patient wants the listed item(s) or service(s), the provider may ask for payment from the patient but must bill Medicare for an official decision on payment. The patient is responsible for payment if Medicare does not pay, but he/she has the right to appeal to Medicare.
    • The patient wants the listed item(s) or service(s) and the provider may ask for payment from the patient, but patient does not want the provider to bill Medicare. Patient loses appeal rights on this option.
    • The patient does not want the listed item(s) or service(s). While the patient is not responsible for payment on this option, he/she also loses appeal rights.
  5. The beneficiary must sign and date the notice, indicating that he/she has received the notice and understands the information on the notice.

http://www.physicianrevenuenav.com/wp-content/uploads/2019/01/ABN-Form-2020.pdf

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2 thoughts on “Advance Beneficiary Notice (ABN)

  1. A lab sometimes will give a patient container to collect samples at home and then bring back to the lab for ordering and resulting. They don’t do a registration/ ordering at the time that they bring the sample back in, they just take the sample and send the patient on their way. If we find that one of the tests are not covered by Medicare can we call back the patient to come back in an sign an ABN after the fact or do they have to sign an ABN as they hand the sample to personnel in the lab before they leave?

    1. An ABN has to be given to the patient in advance of a service. The ABN makes the patient aware that Medicare may not pay for the service and gives him/her the option to have the service at his/her own expense.
      In your scenario, the ABN should really be given to the patient, as well as signed by the patient, at the time sample container is given.

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