ADVANCED BENEFICIARY NOTICE (ABN)
The intent and purpose of an ABN is to notify Medicare beneficiaries, in writing, that a test being ordered for them by their physician may not be paid for by Medicare. The beneficiary has the opportunity to make an informed decision about whether or not to have the test and be financially responsible should Medicare deny payment.
The Medicare program does not cover all services, for many commonly ordered tests (e.g. cholesterol, glucose, Prothrombin Time), Medicare will reimburse only when specific criteria are met. The Centers for Medicare & Medicaid Services (CMS) have developed National Coverage Determinations that govern which diagnoses are considered "reasonable and necessary" according to Medicare rules for reimbursement.
The practitioner should discuss the possibility of claim denial with the patient and the reason(s) the test should be performed so s/he is able to make an informed decision whether or not to proceed with the service.
The ABN consists of four required components: Patient Demographic information (Name, Medical Record Number, Date of Service, Medicare HINC#), The test(s) subject to the ABN, the patient's desire to have the test performed (YES, it should be performed and the patient will pay for it or NO do not perform the test), The patient's signature and date.
EXAMPLE OF PROPERLY FILLED OUT ABN
Medicare allows UPHS – Marquette to bill the patient for a denied test only if an ABN is completed and signed by the patient prior to specimen collection.
Routine or blanket ABNs are prohibited by Medicare where there is no reasonable expectation of non-coverage.
An ABN should be obtained when one or more of the following circumstances exist:
- The diagnosis does not meet medical necessity guidelines.
- The test(s) is for a routine exam or screening.
- The test(s) is for experimental or investigational use.
- The number of times the test(s) can be ordered within a certain time period is limited by Medicare.
- The test(s) has not been approved by the Food and Drug Administration.
- No diagnosis provided.
If any of the previous circumstances exist, fill out an ABN following the steps below.
For validity reasons, the ABN must consist of all necessary components to include the following: Do not invalidate an ABN by leaving any of these areas blank.
- Patient name
- Test(s)
- Estimated cost
- Option 1, option 2, or option 3 checked.
- Reason Medicare may not pay marked (one or more may be marked to indicate the reason for the possible denial)
- Medicare does not pay for these tests for your condition.
- Medicare does not pay for these tests as often as this (denied as too frequent)
- Medicare does not pay for experimental or research use tests
- Patient signature and date.
- MGHS and client customized panels should be billed to Medicare only when every component of the customized panel is medically necessary.
- Medicare National Limitation Amounts for CPT codes are available through CMS or its contractors. Medicaid reimbursement will be equal to or less than the amount of Medicare reimbursement.
For estimated test(s) cost - Contact Wendy Blight, Cory Blight, or Troy Frayer at 906-225-3707.
ABN FORMS
Additional ABN forms are available upon request from client services: 1-888-818-3879
