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:
- Specific names of the items or services believed to be non-covered.
- An explanation of why the provider believes that the item(s) or service(s) that is/are listed may not be covered by Medicare.
- 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.
- 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.
- The beneficiary must sign and date the notice, indicating that he/she has received the notice and understands the information on the notice.
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