The revised Advanced Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is issued by providers (including independent laboratories), physicians, practitioners, and suppliers in situations where Medicare payment is expected to be denied. The revised ABN replaces the ABN-G (Form CMS-R-131G), ABN-L (Form CMS-R-131L), and NEMB (Form CMS-20007). See the revised ABN manual instructions below for detailed instructions on mandatory and voluntary use of the revised ABN.
Note: Skilled nursing facilities (SNFs) must use the revised ABN for items/services expected to be denied under Medicare Part B only.
WHAT IS AN ABN?
An ABN is a written notice that a provider/supplier gives to a Medicare patient before items or services are rendered when the provider/supplier believes Medicare probably/certainly will not pay for some or all of the items or services.
ABNs should only be provided to Medicare beneficiaries. The ABN allows the beneficiary to make an informed decision about whether to receive services that he may be financially responsible for paying. The ABN serves as proof the patient had knowledge prior to receiving the service that Medicare might not pay. If a provider does not deliver a proper ABN to the patient, the patient cannot be billed for the service.
TO WHOM SHOULD AN ABN BE GIVEN?
The Medicare beneficiary.
The Medicare beneficiary’s representative under applicable state or other law. A representative is an individual who may make health care and financial decisions on a beneficiary’s behalf (e.g., legal guardian or someone appointed according to a properly executed “durable medical power of attorney”).
WHEN SHOULD AN ABN BE GIVEN?
Mandatory ABN Uses
An ABN should be given when Medicare is expected to deny payment (entirely or in part) for the item or service because it is not reasonable and necessary under Medicare program standards.
Voluntary ABN Uses
ABNs are not required for care that is statutorily excluded. However, the ABN can be issued voluntarily in place of the NEMB.
Examples of Medicare program exclusions are:
Personal comfort items.
Self-administered drugs and biologicals (i.e., pills and other medications not administered by injections).
Cosmetic surgery (unless required for prompt repair of accidental injury or for improvement of a malformed body member).
Eye exams for the purpose of prescribing, fitting or changing eyeglasses or contact lenses in the absence of disease or injury to the eye.
Routine immunizations (except influenza vaccine, pneumococcal vaccine and hepatitis B vaccine; these services have specific regulations regarding patient responsibility).
Physicals, laboratory tests and X-rays performed for screening purposes (except screening mammograms, screening Pap smears and various other mandated screening services; these services have specific guidelines regarding patient responsibility and when an ABN should be obtained).
X-rays and physical therapy provided by chiropractors.
Hearing aids and hearing examinations.
Routine dental services (i.e., care, treatment, filling, removal or replacement of teeth).
Supportive devices for the feet.
Routine foot care (i.e., cutting or trimming corns or calluses, unless inflamed or infected; routine hygiene or palliative care or trimming of nails).
Services furnished or paid by government institutions.
Services resulting from acts of war.
Charges made to the Medicare program for services furnished by a physician or supplier to his immediate relatives or members of his household. The following relationships are included in the definition of immediate relative: husband and wife; natural parent, child and sibling; adopted child and adoptive parent, adopted sibling; stepparent, stepchild, stepbrother and stepsister; father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law and sister-in-law; grandparent and grandchild; and spouse of grandparent or grandchild. By definition, members of the household include those persons sharing a common abode with the physician as part of a single family unit, including those related by blood, marriage or adoption; domestic employees; and others who live together as part of a single family unit.
HOW LONG SHOULD AN ABN BE KEPT ON FILE?
In general, the ABN should be kept for five years from discharge/completion of delivery of care when there are no other applicable requirements under state law. Providers are required to keep a record of the ABN in all cases, including those cases in which the beneficiary declined the care, refused to choose an option or refused to sign the notice.
What if Beneficiary Refuses to Complete or Sign the Notice?
If the beneficiary refuses to choose an option and/or refuses to sign the ABN, the provider should annotate the original copy of the ABN indicating the refusal to sign and may list witness(es) to the refusal on the notice although this is not required. If a beneficiary refuses to sign a properly delivered ABN, the provider should consider not furnishing the item/service, unless the consequences (health and safety of the patient, or civil liability in case of harm) are such that this is not an option.
Providers may not issue ABNs to shift financial liability to a beneficiary when full payment is made through bundled payments (e.g., National Correct Coding Initiative).
ABNs cannot be used when the beneficiary would otherwise not be financially liable for payments for the service because Medicare made full payment.