GA - JE Part A

Definition

Waiver of liability statement issued as required by payer. The provider has provided an Advance Beneficiary Notice of Noncoverage (ABN) to the patient.

Appropriate Usage

• Append when ABN provided and denial expected on an item or service as it is not reasonable and necessary
• Append when ABN provided and provider determines services will not be covered based on an active Local Coverage Determination (LCD)
• Append when ABN provided and if Medicare determines that service is not payable, claim denial is under a "medical necessity denial"

Inappropriate Usage

• Appending when provider has no expectation that an item or service will be denied
• Appending on a routine basis for all services performed by provider

Resource

• CMS Internet Only Manual (IOM), Medicare Claims Process Manual, Publication 100-04, Chapter 1, section 60.4.2