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 May 17, 2017