Preventive Screening Benefits ABN Requirements

Some Medicare preventive benefits are subject to frequency limits, and are also specifically cited at section 1862 (a) (1) (F) ff of the Act as subject to "medical necessity." There has been some confusion as to the basis of denial and how such services are adjudicated. When medical necessity is the basis for denial an Advance Beneficiary Notice of Noncoverage (ABN) is necessary in order to shift the liability to the beneficiary, and special ABN-related billing must be used.

Services that do not meet the medical necessity/frequency limits and fail to have an ABN issued to the beneficiary prior to performing the services will have these line items deny as provider liable.

The Medicare claims processing system will look for the medical necessity of the preventive service first, then look towards the frequency to see if the beneficiary meets the qualifications as defined for all preventive services. Providers will be required to submit the appropriate modifier (i.e. GA, GZ) charges in covered, and the 32 occurrence code for each date of service where an ABN was issued and the claims processing system will deny accordingly. 

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Last Updated Tue, 11 Feb 2020 12:58:06 +0000