Advance Beneficiary Notice of Noncoverage (ABN) - JE Part B

An ABN, Form CMS-R-131, is a standardized notice that a health care provider/supplier must give to a Medicare beneficiary, before providing certain Medicare Part B or Part A items or services.

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Overview

The ABN must be issued to a beneficiary with enough time prior to the service/procedure for the beneficiary to make an informed decision about whether, or not, to have the procedure/service. It must be issued when the health care provider (including independent laboratories, physicians, practitioners and suppliers) believes that Medicare may not pay for an item or service because of medical necessity, frequency limitations, discontinued services, experimental and investigational, and not safe or proven effective.

By providing the ABN in advance of the procedure/service, it gives a beneficiary the opportunity to decide whether to receive the service and accept financial responsibility if denied by Medicare. It also serves as proof that the beneficiary was advised of potential financial responsibility. If the provider does not deliver a valid ABN to the beneficiary, the beneficiary cannot be billed.

CMS strongly encourages healthcare providers and suppliers to issue an ABN for care that is never covered. However, an ABN is not required for care that is either statutorily excluded from coverage under Medicare (care that is never covered) or most care that fails to meet a technical benefit requirement (lacks required certification). An ABN must not be used for all services and is not required for services that are statutorily excluded. Such as: vitamins, nutritional counseling, x-rays, office visit, and therapy.

Once an ABN is issued, it is no longer required to be issued annually. An ABN remains effective as long as there is no change in: care from what is described on the original ABN, beneficiary’s health status or Medicare coverage guidelines.

If there are ANY changes, a new ABN is required.

Medical Necessity

Medical Necessity is defined as services that are reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member and are not excluded under another provision of the Medicare Program.

Coverage of certain items/services is limited by the diagnosis. If the diagnosis listed on the claim is deemed not medically necessary, the procedure is denied. Limited coverage may be the result of National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs). The CMS Medicare Coverage Database (MCD) contains all NCDs and LCDs, local policy articles and proposed NCD decisions. View the CMS NCDs. The official versions of LCDs may be viewed by contractor, state or alphabetically.

42 C.F.R.411.406 states that a healthcare provider or supplier that furnished services which constitute custodial care under 411.15(g) or that are not reasonable and necessary under 411.15(k) is considered to have known that the services were not covered if any one of the conditions listed below are met:

  1. Notice from the Quality Improvement Organization (QIO), intermediary or carrier. The QIO, intermediary or carrier had informed the provider, practitioner or supplier that the services furnished were not covered or that similar or reasonably comparable services were not covered.
  2. Notice from the utilization review committee or the beneficiary's attending physician. The utilization review group or committee for the provider or the beneficiary's attending physician had informed the provider that these services were not covered.
  3. Notice from the provider, practitioner or supplier to the beneficiary. Before the services were furnished, the provider, practitioner or supplier informed the beneficiary that
    1. The services were not covered; or
    2. The beneficiary no longer needed covered services.
    1. Its receipt of CMS notices, including manual issuances, bulletins, or other written guides or directives from intermediaries, carriers or QIOs including notification of QIO screening criteria specific to the condition of the beneficiary for whom the furnished services are at issue and of medical procedures subject to preadmission review by the QIO.
    2. Federal Register publications containing notice of national coverage decisions or of other specifications regarding non-coverage of an item or service.
    3. Its knowledge of what are considered acceptable standards of practice by the local medical community.

    ABN Triggering Events

    An ABN is required when an item or service is expected to be denied. This may occur at any one of three points during a course of treatment which are initiation, reduction and termination, also known as "triggering events."

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