Target Audience: Medicare Fee-For-Service Providers
How to Access This Educational Tool
Access this educational tool by either clicking on the section tabs above or scrolling down to each section below.
Using the ABN Interactive Tutorial
You may select any field (letters A. – J.) in the interactive form for more detailed instructions.
The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, helps a Medicare Fee-For-Service (FFS) beneficiary make an informed decision about items and services Medicare usually covers but may not pay because they are medically unnecessary. If a beneficiary does not get written notice when required, they may not be financially liable if Medicare denies payment, and the provider or supplier may be financially liable.
In situations when a Medicare payment denial is expected, all health care providers and suppliers must issue an ABN, including:
- Independent laboratories, Skilled Nursing Facilities (SNFs), and home health agencies (HHAs) providing Medicare Part B (outpatient) items and services
- Hospice providers, HHAs, and Religious Nonmedical Health Care Institutions providing Part A items and services
This interactive tutorial helps health care providers and suppliers properly complete an ABN form.
TO ACCESS THE ABN INTERACTIVE TUTORIAL, CLOSE THE INTRODUCTION WINDOW.
You must issue an ABN:
- When an item or service is not reasonable and necessary under Medicare Program standards. Common reasons for Medicare to deny an item or service as not medically reasonable and necessary include care that is:
- Experimental and investigational or considered “research only”
- Not indicated for diagnosis or treatment in this case
- Not considered safe and effective
- More than the number of services Medicare allows in a specific period for the corresponding diagnosis
- When custodial care is furnished
- When outpatient therapy services exceed therapy cap amounts and do not qualify for a therapy cap exception
- Before caring for a beneficiary who is not terminally ill (hospice providers)
- Before caring for a beneficiary who is not confined to the home or does not need intermittent skilled nursing care (home health providers)
- Before furnishing an item or service Medicare will not pay because (durable medical equipment, prosthetics, orthotics, and supplies [DMEPOS] suppliers):
- The provider violated the prohibition against unsolicited telephone contacts
- The supplier has not met supplier number requirements
- The supplier is a non-contract supplier furnishing an item listed in a competitive bidding area
- The beneficiary wants the item or service before Medicare receives the advance coverage determination
Do not use an ABN for items and services you furnish under Medicare Advantage (Part C) or the Medicare Prescription Drug Benefit (Part D).
You are not required to notify the beneficiary before you furnish items or services that are not a Medicare benefit or that Medicare never covers, such as:
- Services when there is no legal obligation to pay
- Services authorized or paid by a government entity other than Medicare (this exclusion does not include services paid by Medicaid on behalf of dual-eligibles)
- Services required because of war
- Personal comfort items such as radios and televisions
- Eye examinations for prescribing, fitting, or changing eyeglasses
- Hearing aids
You may issue a voluntary advance written notice of noncoverage or a similar notice as a courtesy to alert the beneficiary about their financial liability.
An ABN is valid if you:
- Use the most recent version of the ABN
- Use a single ABN for an extended course of treatment for no longer than 1 year
- Complete the entire form
- Ensure that the beneficiary understands the meaning of the notice
What If the Beneficiary or the Beneficiary’s Representative Refuses to Choose an Option or Sign the ABN?
If the beneficiary or the beneficiary’s representative refuses to choose an option or sign the ABN, you should annotate the original copy indicating the refusal to choose an option or sign the ABN. You may list any witnesses to the refusal, although a witness is not required. If a beneficiary refuses to sign a properly issued ABN, consider not furnishing the item or service unless the consequences (health and safety of the beneficiary or civil liability in case of harm) prevent this option.
TO ACCESS THE ABN INTERACTIVE TUTORIAL, CLOSE THE BACKGROUND WINDOW.
ABN INTERACTIVE TUTORIAL
In the ABN tutorial, select any field (letters A. – J.) for details on how to complete each section of the ABN form.
On the ABN form, the term “you” refers to the beneficiary who signs the ABN. In the ABN interactive tutorial instructions, “you” refers to the provider issuing the form.
If you reproduce the ABN form, remove the letters before issuing it to the beneficiary.
- 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.
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 (HICN) card or Medicare Beneficiary Identifier (MBI) 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.
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 (HICNs), MBI numbers or Social Security numbers must not appear on the notice.
First D. field in ABN
The following descriptors may be used in the first D. field:
- Laboratory test
Second D. field in ABN
Insert the wording used in the first D. field.
Field D. under “What You Need To Do Now”
Insert the wording used in the first D. field.
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 50.7.1 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
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
- 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. For example, a single cost estimate can be given for a group of laboratory tests, such as a basic metabolic panel (BMP).
Complete the three D. Blanks under the G. Options section with the same wording used in the first D. field. The beneficiary, or his or her representative, must choose one of the three options listed. Medicare does not permit you to make this selection. (However, HHAs caring for dual eligibles [beneficiaries eligible for both Medicare and Medicaid] may direct beneficiaries to select a particular option box according to State directives. For more information, refer to Correction CR – Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R131.)
NOTE: When you issue the ABN as a voluntary notice, the beneficiary does not need to check an option box or sign and date the notice.
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
Insert the wording used in the first D. field.
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.
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.
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.
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.
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.
|For More Information About…||Resource|
Chapter 30, Section 50 of the Medicare Claims Processing Manual (Publication 100-04)
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