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 15, 2017