© 2012 Copyright, CGS Administrators, LLC. Revised ... · representative in person if possible When in-person delivery is not possible, delivery may be • Telephone contact •

© 2012 Copyright, CGS Administrators, LLC. Revised February 28, 2012.

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© 2012 Copyright, CGS Administrators, LLC. Revised February 28, 2012. © 2012 Copyright, CGS Administrators, LLC. Revised February 28, 2012.

For an ABN to be acceptable, it must: Be presented on the approved form:

• Beginning January 1, 2012

• CMS-R-131(03/11) Form http://www.cms.gov/BNI.02_ABN.asp

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http://www.cms.gov/BNI.02_ABN.asp


An acceptable ABN must: Clearly identify the supplier name, address and telephone

Clearly identify the beneficiary

Must be issued prior to dispensing the item or providing the service

Clearly identify item or service to be provided

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Clearly state reason for belief that Medicare will likely deny payment

Include estimated cost

Be received by, and contents comprehended by, the beneficiary (or authorized representative)

Be signed and dated by the beneficiary or representative

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A person acting on the beneficiary’s behalf and in his/her best interests.

Examples include:

• A spouse (unless legally separated)

• An adult child

• A parent

• An adult sibling

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ABNs are designed for use with Medicare beneficiaries only.

Not for use with Medicare Advantage enrollees or non-Medicare patients.

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There are three specific triggering events: Initiation: If you believe the item or service being provided may

be denied by Medicare as not medically necessary

Reduction: When there is a decrease in the frequency or duration

Termination: The discontinuation of items/services

NOTE: ABNs should not be given unless there is genuine belief Medicare will deny payment

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Stating “Medically unnecessary” is not an acceptable reason.

Some examples of acceptable denial statements are as follows:

• Medicare does not pay for this item or service for your condition.

• Medicare does not pay for this item or service more often than ___________(insert frequency limit).

• Medicare does not pay for services which it considers to be experimental or for research use.

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“Routine” is defined as giving beneficiaries ABNs where there is no reasonable expectation of noncoverage.

Giving routine notices for all claims or services is not an acceptable practice.

Blanket or generic ABNs are also not acceptable.

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ABNs may be routinely given only in the following exceptional circumstances:

Items or services which are always denied for medical necessity (NCDs/LCDs)

Experimental items or services

Certain frequency-limited items and services

Note: 100-04, 40.3.6.4

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Do not use italics or any font that is difficult to read.

Use at least a 12-point font size.

Use a visually high-contrast combination of dark ink on a pale background.

Do not use block-shade (“highlight”) notice text.

Insertions in forms’ blanks, if any, must be typed, printed, or legibly handwritten.

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Notifier section

“Items or Services” box

“Reason Medicare May Not Pay” box

“Estimated Cost” box

Designed as letter-size form, but may be expanded to legal-size

• May only be one page in length

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Ten blanks required for completion

• Lettered A-J

A-F and H may be completed prior to delivery of the notice

Typed or legibly handwritten

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A: Name, address and telephone number of Notifier (may use logo or label)

B: Patient name (first, last, and middle initial, if on Medicare card)

C: ID number to link ABN to related claim, optional (Do not use the HICN or SSN)

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D: Items or services • Must include all items/services subject to the

notice • If technical language is used, it must be

verbally explained • Never permissible to add items/services after

notice is signed

E: Reason Medicare may not • Explanation of why Medicare may not cover

the item or service • At least one reason for each item or service

listed on the notice • The same reason may apply to multiple

items/services

F: Estimated cost • Enter a cost estimate for all items or services in D • Estimate may be individual or total cost • ABN will not be considered valid without a good

faith effort to estimate cost

Example: For a service that costs $250 • Any dollar estimate equal to or greater than $150 • “Between $150 -$300” • “No more than $500”

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G: Beneficiary Options • Must be completed by the beneficiary • Only one option should be checked • If the beneficiary cannot or will not make a choice, the notice should be annotated • If the beneficiary chooses to accept some but not all items/services

- Cross out items/services refused, reason for those items, and cost estimate, OR - Complete a new ABN

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Option 1: Beneficiary Options • Beneficiary elects to receive item/service and

have the claim submitted to Medicare • May collect payment at time item/service delivered • If Medicare pays, provider refunds beneficiary

- If denied, beneficiary responsible for cost - Appeal rights if denied

Option 2: Beneficiary elects to receive item/service, but does not want a claim submitted to Medicare

• May collect payment at time item/service delivered

• Beneficiary responsible for cost • No appeal rights

Option 3: Beneficiary elects to decline the item or service • No payment to be made by Medicare • Cannot appeal to see if Medicare would pay 17


H: Additional Information • May be used to provide additional information of use to the beneficiary • Contains a statement telling the beneficiary that the ABN gives the

provider’s opinion, and does not represent an official Medicare decision • Provides the 1.800.MEDICARE number

I: Signature • Beneficiary (or representative) must sign indicating that they

received and understood the notice

J: Date • Beneficiary (or representative) must

enter the date they signed the ABN

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The ABN must be given prior to the service being rendered.

The ABN should be delivered to the beneficiary or authorized representative in person if possible

When in-person delivery is not possible, delivery may be

• Telephone contact

• Mail

• Secure fax

• Internet e-mail

• NOTE: All methods of delivery must adhere to HIPPA requirements and be validated by the beneficiary

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The beneficiary must be able to comprehend the notice and select an option.

You must explain in its entirety and answer beneficiary questions.

Signed by th4 beneficiary or the representative

Keep original form on file and provide the beneficiary a copy.

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ABNs are not required for statutorily excluded items and services such as:

• Personal comfort items

• Cosmetic surgery, etc.

Claims for non-covered services or supplies are not required to be filed to Medicare.

• Unless the patient requests that the claim be filed.

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Beneficiary receives an ABN, refuses to sign it, but still insists that the service be provided?

“Limitation of Liability,” which requires notification but not signature, applies

• annotate ABN with signature of witness

• submit claim with “GA” modifier

• may bill patient if claim denies

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Beneficiary refuses to sign the ABN and declines service?

The beneficiary must choose Option #3 on the ABN form with the understanding that the item/service will not be provided.

Remember, the provider may choose to refuse to provide service at any time when a patient refuses to sign the ABN.

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GA - Signed ABN on file (expected to be denied as not reasonable and necessary)

GK - Standard item ordered by physician (REASONABLE AND NECESSARY)

GZ - No ABN on file (Item not reasonable and necessary expected to be denied)

GL - Free upgrade (patient not liable)

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Use GA modifier

• When ABN is properly executed and signed by the beneficiary

• On an assigned claim if beneficiary refused to sign (form must be annotated by a witness)

What happens when you use this modifier?

• Protects notifier from liability from denial

• Beneficiary is liable for full charge

• PR denial

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Use GK modifier

• Reasonable and necessary item

• When ABN is properly executed and signed by the beneficiary for upgraded items

What happens when you use this modifier?

• Protects provider from liability

• Beneficiary is charged the difference between standard and upgrade item

• PR denial

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01/23/08-01/23/08 12 K0005 RRKHGA 1 900.00 1 1225104517

01/23/08-01/23/08 12 K0004 RRKHGK 1 500.00 1 1225104517

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Use this modifier if you expect item to deny as not reasonable and necessary

Do not have a signed ABN

Example:

• Patient not present and could not be reached timely

Modifier does not influence coverage determination

• If Medicare denies, beneficiary is not liable

Use of this modifier is voluntary and informational only

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Use this modifier to indicate service is statutorily excluded or non-covered by Medicare

• There is no requirement to file claim unless patient requests claim to be submitted

Beneficiary is liable for all charges related to non-covered care

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CMS Manual System

• https://www.cms.gov/Manuals/IOM/

Medicare Claims Processing Manual Pub.100-4, Chapter 30 – Financial Liability Protections

• http://www.cms.gov/BNI/Downloads/RevABNManualInstructions.pdf

• Questions regarding the use of the revised ABN form may be emailed to: - [email protected]

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https://www.cms.gov/Manuals/IOM/

http://www.cms.gov/BNI/Downloads/RevABNManualInstructions.pdf

mailto:[email protected]


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Interactive Voice Response (IVR) Unit: 1.866.238.9650

Customer Service: 1.866.270.4909

Telephone Re-openings: 1.866.813.7878

Paper Claim Submission, Adjustment Requests (Reopenings), EFT Form Submission, and Written Inquiries Address: CGS PO Box 20010 Nashville, TN 37202

Redetermination Requests:

• Address: CGS PO Box 20009 Nashville, TN 37202

• Fax: 1.615.782.4630 33


PDAC formerly SADMERC

• 1.877.735.1326

• http://www.dmepdac.com

National Supplier Clearinghouse

• 1.866.238.9652

• http://www.palmettogba.com/nsc

CEDI

• 1.866.311.9184

• http://www.ngscedi.com

• [email protected] 34

http://www.dmepdac.com/

http://www.palmettogba.com/nsc

http://www.ngscedi.com/

mailto:[email protected]


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• Click on the ListServ link;

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This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference.

This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

The Centers for Medicare & Medicaid Services (CMS) employees; agents, including CIGNA Government Services (CGS) and its staff; and CMS’ staff make no representation, warranty, or guarantee that this compilation of Medicare information is error free and will bear no responsibility or liability for the results or consequences of the use of this guide. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.

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© 2012 Copyright, CGS Administrators, LLC. Revised ... · representative in person if possible When in-person delivery is not possible, delivery may be • Telephone contact •