Advance Beneficiary Notice of Noncoverage (ABN) Form Tutorial

For more information on how to complete the ABN form, move your cursor over any field in the interactive form below; you'll see instructions on how to complete the field. You may also click in any field for more detailed instructions

Advance Beneficiary Notice of Noncoverage (ABN) Form

• Enter providers name, address, phone number (include TTY, if applicable)
• Handwrite, type, copy office letterhead, or incorporate Notifier's logo • Enter patient/beneficiary first and last name (include middle initial, if on Medicare card) • Enter an internal identification number that will link this notice to a related claim
• Do not use Medicare number or SSN
• This field is not required • List specific item/service and its general description thought to be noncovered.
    - Item
    - Test
    - Service
    - Procedure
    - Care
    - Equipment
    - Supplies
• May combine services/items in same group together. Example: Wound care supplies
• Different items/services must be listed individually.
• In case of partial denial, must list excess component(s) of item/service for expected denial. • Explain in patient/beneficiary-friendly language why Medicare may not cover item/service
• Appropriate examples of noncoverage reasons:
    - Condition of test
    - Frequency of test, item or supply
    - Experimental/research use
• Inappropriate/Vague examples/terms of noncoverage reasons. Not acceptable.
    - • Enter estimated cost of noncovered item/service
    - Show good faith effort by inserting reasonable amount within $100 or 25% of cost. An estimate that exceeds actual cost is generally accepted since the less-than-predicted costs would not harm the patient/beneficiary.
• Multiple items/services routinely grouped may be bundled into single cost estimate.
• This will ensure the patient/beneficiary has all available information to make an informed decision on obtaining potentially noncovered item/service. • If patient/beneficiary chooses this option, they receive item/service at issue.
• Notifier is required to submit a claim to Medicare.
• Payment decision can be appealed.
• If patient/beneficiary needs official Medicare decision in order to file a claim to secondary insurance, they should choose this option. • If patient/beneficiary chooses this option, they receive item/service at issue and pay for them out of pocket.
• Notifier does not bill claim to Medicare.
• No appeal rights. • If patient/beneficiary chooses this option, they refuse to receive item/service at issue.
• Optional: Patient/beneficiary signs and Notifier keeps original on file.
• Notifier does not bill claim to Medicare.
• No appeal rights. • Provide additional clarification that may assist the patient/beneficiary.
• Examples:
    - Statement indicating other patient/beneficiary insurance coverage.
    - Additional witness signature and date. • Patient/beneficiary or representative signature.
    - If representative signs, he/she must write • Patient/beneficiary or representative must enter date ABN was signed.
• Notifier may complete, only if patient/beneficiary has physical trouble writing and requests assistance.
• If no date is entered, ABN is considered incomplete/invalid.

Last Updated Tue, 30 Jun 2020 19:12:08 +0000