March 6, 2018 – Updated 02.21.22
Advance Beneficiary Notice of Noncoverage (ABN) Completion Tips
Medicare Claims Processing Manual (Pub. 100-04, Ch. 30, § 50.5 – 50.6
).
The CGS Medical Review department has noticed easily curable errors when completing the Advance Beneficiary Notice of Noncoverage (Include ABNs with each Additional Documentation Request (ADR) submission, as applicable.).
Completing the header:
- Header: Blanks A-C, the header of the notice, must be completed by the notifier prior to delivering the ABN.
- Blank (A) Notifier(s): 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.
Completing ALL 7 Blank (D) descriptors:
- 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.
Blank (E) Reason Medicare May Not Pay:
- Reason(s) for why a service is not covered by Medicare need to be clear and specific
- 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.
Home Health- the care is not medically reasonable and necessary,
- the beneficiary is not confined to his/her home (considered homebound),
- Patient does not meet homebound criteria, leaves home frequently without assistance or assistive device for shopping.
- the beneficiary does not need skilled nursing care on an intermittent basis, or
- the beneficiary is receiving custodial care only.
- Nursing is not providing a skilled service, filling a medication planner only.
- Ensure clinical documentation in the medical record supports the reason(s) Medicare may not pay for the services listed in Blank (D).
Selecting Blank (G) Options:
- Option Box 1, 2 and 3 are required to be present on the form. One of the check boxes MUST be selected.
- If the beneficiary cannot or will not make a choice, the notice should be annotated (e.g., Beneficiary refused to choose an option.).
- Dually eligible beneficiaries must be instructed to check Option Box 1 on the ABN in order for a claim to be submitted for Medicare adjudication.
- The provider must strike through Option Box 1 as follows:
☑ OPTION 1. I want the (D) listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN.
Use of abbreviations:
- HHAs must avoid using abbreviations in the body of the notice unless the abbreviation is already spelled out elsewhere. For example, an abbreviation such as "PT" that can have multiple meanings in a home health setting (part-time, physical therapy, prothrombin time) should be spelled out at least once on the ABN next to the abbreviation of the word(s). When this is done, the abbreviation can be used again on the notice. ABNs containing abbreviations that are not defined in this manner on the notice may be invalidated by contractors.
Cost estimate is unclear:
- HHAs should follow the ABN form instruction guidelines for providing cost estimates for items or services. The cost estimate must be a good faith estimate based on agency charges and the expected frequency and duration of each service. Cost estimates per visit or per number of visits weekly are acceptable. A difference in the cost estimate and actual cost will not automatically invalidate the ABN. The cost estimate must give the beneficiary an idea of what his/her out of pocket costs might be if s/he chooses to receive the care listed on the ABN.
Cost estimate examples:
$440 for 4 weekly nursing visits in 1/13.
$260 for 3 physical therapy visits 1/3-1/7/13.
$50 for spare right arm splint.
When more than one item and/or service is at issue, the HHA must enter separate cost estimates for each item or service as clearly as possible, including information on the period of time involved when appropriate.
Effective Versions:
ABNs are effective as of the OMB approval or expiration date given at the bottom of each notice. Notifiers are expected to exclusively use the current version of the ABN.
Additional resources to assist in completing the ABN include:
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