What is an ABN and When Might You Need One?

An Advance Notice of Beneficiary Notice of Non-Coverage (ABN) is a document your provider must supply you with if he or she thinks Medicare won’t pay for an item or service because they believe it is not medically reasonable and necessary. The purpose of the form is to let you know that you may have to pay for a service that would otherwise be covered by Medicare, if it were medically reasonable and necessary.

An ABN comes in a prescribed format. It must:

1. Be easy to understand
2. Be straightforward in identifying the item or service that the provider does not expect Medicare to cover
3. Tell you with the costs of the item or service, should you choose to have them
4. Give very specific information as to why the item or service might be denied by Medicare
5. Be explained to you to ensure understanding and to allow you to ask questions
6. Be given to you with enough advance notice that you are able to make an informed decision

An ABN contains three options for you to select from:
Option 1 indicates you want to have the item or service performed, even if Medicare does not pay for it. However, you want the provider to bill Medicare for the service, and if the claim is denied, you can file an appeal. You also agree to pay for the service yourself if the provider asks you to pay for it before the claim is submitted to Medicare.

Option 2 indicates that you want to have the item or service performed, but you do not want your provider to bill Medicare. In this case, you cannot appeal a decision, as no claim has been filed. You agree to pay for the item or services at the time they are provided.

Option 3 indicates that you don’t want the items or services that Medicare may not pay, and that you are not responsible for any payments (since no service has been rendered). No claim is filed to Medicare, and an appeal cannot be requested as there was no claim from which to appeal.

Note: in an emergency situation (to include an emergency ambulance transport), an ABN cannot be issued to you at that time. A provider can issue an ABN when you are medically stable and able to make informed decisions.

Is an ABN Issued for All Non-Covered Services?
ABNs are required to be issued for Medicare-covered services that your physician or supplier thinks are not medically reasonable and necessary for you at the time. An ABN can be issued, as a courtesy, for items or services never covered by Medicare, though it is not required in these cases.

If you have questions about the ABN, please call our Beneficiary Contact Center at 800-833-4455, between 8:30 a.m. and 7 p.m. ET Monday through Friday. We encourage you to visit our Facebook page called 'My RR Medicare' at www.facebook.com/MyRRMedicare and our free Beneficiary Portal at www.PalmettoGBA.com/MyRRMed. MyRRMed offers you the ability to access claims data, historical Medicare Summary Notices (MSN), and a listing of individuals you have authorized to have access to your personal health information.