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
Blank (A) Notifier(s): Enter providers name, address, phone number (include TTY, if applicable). Handwrite, type, copy office letterhead, or incorporate Notifier's logo. Blank (B) Patient Name: Enter patient/beneficiary first and last name (include middle initial, if on Medicare card). Blank (C) Identification Number: 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. Blank (D): 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. Blank (E) Reason Medicare May Not Pay: 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 are not acceptable. Blank (F) Estimated Cost: 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. OPTION 1: 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. OPTION 2: 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. OPTION 3: 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. Blank (H) Additional Information: Provide additional clarification that may assist the patient/beneficiary. Examples: Statement indicating other patient/beneficiary insurance coverage, Additional witness signature and date. Blank (I) Signature: Patient/beneficiary or representative signature. If representative signs, he/she must write out representative in parentheses after his or her signature. Blank (J) Date: 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 01 , 2023