LICENSES AND NOTICES

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA websiteExternal Website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association websiteExternal Website.
  3. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
  4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
  5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.


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Advance Beneficiary Notice of Noncoverage (ABN) Form Instructions Tool

Hover over each highlighted section to better understand this form.

Medicare information Medicare information
Medicare information NOTIFIER

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.
Medicare information Medicare information
Medicare information IDENTIFICATION NUMBER

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 or Social Security numbers must not appear on the notice.
Medicare information Medicare information
Medicare information Medicare information
PATIENT NAME

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 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.
Medicare information
Medicare information Medicare information Medicare information
Medicare information First D. field in ABN

First D. field in ABN

The following descriptors may be used in the first D. field:

  • Item
  • Service
  • Laboratory test
  • Test
  • Procedure
  • Care
  • Equipment
Medicare information Medicare information
Medicare information Medicare information
Medicare information Second D. field in ABN

Second D. field in ABN

  • Insert the wording used in the first D. field.
Medicare information Medicare information
Medicare information Medicare information Medicare information Medicare information
Medicare information Medicare information
First column in Table D

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 50.7.1External PDF 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

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

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.

Medicare information Medicare information
Medicare information Medicare information
Medicare information Field D. under “What You Need To Do Now”

Field D. under “What You Need To Do Now”

  • Insert the wording used in the first D. field.
Medicare information Medicare information
Medicare information Medicare information
Medicare information OPTION 1

Option 1

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.

Medicare information Field D. under G. Options

Field D. under G. Options

  • Insert the wording used in the first D. field.
Medicare information Medicare information
Medicare information Medicare information Medicare information
OPTION 2

Option 2

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.

Field D. under G. Options

Field D. under G. Options

  • Insert the wording used in the first D. field.
Medicare information Medicare information
Medicare information Medicare information Medicare information
Option 3

Option 3

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.

Medicare information Field D. under G. Options

Field D. under G. Options

  • Insert the wording used in the first D. field.
Medicare information Medicare information
Medicare information Medicare information Medicare information
Medicare information Additional Information

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.

Special guidance ONLY for non-participating suppliers and providers (those who don't accept Medicare assignment):

Strike the last sentence in the Option 1 paragraph with a single line so that it appears like this: If Medicare does pay, you will refund any payments I made to you, less co- pays or deductibles.

This single line strike can be included on ABNs printed specifically for issuance when unassigned items and services are furnished. Alternatively, the line can be hand-penned on an already printed ABN.

The sentence must be stricken and can't be entirely concealed or deleted.

There is no CMS requirement for suppliers or the beneficiary to place initials next to the stricken sentence or date the annotations when the notifier makes the changes to the ABN before issuing the notice to the beneficiary.

When this sentence is stricken, the supplier shall include the following CMS-approved unassigned claim statement in the (H) Additional Information section.

"This supplier doesn't accept payment from Medicare for the item(s) listed in the table above. If I checked Option 1 above, I am responsible for paying the supplier's charge for the item(s) directly to the supplier. If Medicare does pay, Medicare will pay me the Medicare-approved amount for the item(s), and this payment to me may be less than the supplier's charge."

  • This statement can be included on ABNs printed for unassigned items and services, or it can be handwritten in a legible 10 point or larger font.
  • An ABN with the Option 1 sentence stricken must contain the CMS-approved unassigned claim statement as written above to be considered valid notice. Similarly, when the unassigned claim statement is included in the "Additional Information" section, the last sentence in Option 1 should be stricken
Medicare information
Medicare information Medicare information
Medicare information SIGNATURE

I. Signature

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.

DATE

J. Date

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.

Medicare information
Medicare information Medicare information
Medicare information Medicare information Medicare information Medicare information Medicare information Medicare information Medicare information Medicare information Medicare information Medicare information Medicare information Medicare information Medicare information Medicare information Medicare information Medicare information Medicare information Medicare information Medicare information Medicare information Medicare information Medicare information Medicare information Medicare information Medicare information

The ABN form, completion instructions, and manual instructions are located on the CMS websiteExternal Website.

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