Advanced Beneficiary Notice (ABN) and Complex Medical Record Review

Posted January 13, 2011

Noridian Medical Review will request that any mandatory ABNs on file be submitted with all other requested documentation specified in Additional Documentation Request (ADR) letters for all complex medical reviews.

Suppliers are reminded to reference the CMS Internet Online Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Sections 50.3.1 and 50.3.2 which states the following in regard to ABN requirements:

50.3.1 - Mandatory ABN Uses

The following are statutory provisions requiring delivery of the ABN:

  • §1862(a)(1) of the Act (not reasonable and necessary);
  • §1834(a)(17)(B) of the Act (violation of the prohibition on unsolicited telephone contacts);
  • §1834(j)(1) of the Act (medical equipment and supplies supplier number requirements not met);
  • §1834(a)(15) of the Act (medical equipment and/or supplies denied in advance).
  • §1862(a)(9) of the Act (custodial care);
  • §1879(g)(2) of the Act (hospice patient who is not terminally ill).

50.3.2 - Voluntary ABN Uses

ABNs are not required for care that is either statutorily excluded from coverage under Medicare (i.e. care that is never covered) or fails to meet a technical benefit requirement (i.e. lacks required certification). However, the ABN can be issued voluntarily in place of the Notice of Exclusion from Medicare Benefits (NEMB) for care that is never covered such as:

  • Care that fails to meet the definition of a Medicare benefit as defined in §1861 of the Social Security Act;
  • Care that is explicitly excluded from coverage under §1862 of the Social Security Act. Examples include:
    • Services for which there is no legal obligation to pay;
    • Services paid for by a government entity other than Medicare (this exclusion does not include services paid for by Medicaid on behalf of dual-eligibles);
    • Services required as a result of war;
    • Personal comfort items;
    • Routine physicals and most screening tests;
    • Routine eye care;
    • Dental care; and
    • Routine foot care.

Suppliers are reminded that in order to avoid unnecessary denials for missing or incomplete information, please ensure when responding to an ADR that all requested information is included with your file and respond in a timely manner.

Last Updated Aug 22 , 2017