Although Medicare’s Advance Beneficiary Notice of Noncoverage (ABN) has been in use for many years, we still encounter confusion among our clients about proper use of the form.

Q. What is an ABN and why do we need one?

A. An ABN is a written notice a health-care provider gives to a Medicare beneficiary when the provider believes that Medicare will not pay for some or all of the items or services the patient will receive. The ABN form changes periodically. The newest ABN form is required for dates of service on or after Aug. 31, 2020, although there was some leeway granted during the public health emergency.

Get a signed ABN when you believe that Medicare is likely to deny your claim for a service you plan to provide. Always get it signed in advance. By signing an ABN, the Medicare beneficiary acknowledges that Medicare will probably or certainly not pay and agrees to be responsible for payment, either personally or through another insurance.

Q. We want to customize the ABN form; is this permitted?

A. Yes, in part. You must add your name, address and telephone to the header. You may add your logo and other information if you wish. The “Items or Services,” “Reason Medicare May Not Pay,” and “Estimated Cost” boxes are customizable, so you can add preprinted lists of common items and services or denial reasons. Anything you add in the boxes must be in high-contrast ink on a pale background; blue or black ink on white paper is preferred.

You may not make any other alterations to the form. It must be 1 page, single-sided, and the reverse side must be blank. Addenda are allowed. Be sure to keep a copy.

Instructions given in November 2013 note that the ABN can be executed and saved electronically, but the beneficiary must be offered a paper version as well. As of September 2017, a paper ABN can be scanned and retained electronically after being signed and dated (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ABN_Booklet_ICN006266.pdf ).

Q. How do we complete the form?

A. Fill in the beneficiary’s name and your patient ID (not Medicare number) at the top of the form. Complete the “Items or Services” box, describing what you propose to provide. Use language the beneficiary can understand. You may add CPT or HCPCS codes, but a description is required. Complete the “Reason Medicare May Not Pay” box with the reason(s) you expect a denial. The reason(s) must be specific to the particular situation; general statements such as “medically unnecessary” are not acceptable. The “Estimated Cost” field is required.

You must complete your portion of the form before asking the beneficiary to sign. The beneficiary or representative must choose Option 1, 2, or 3 (options detailed below). The patient must sign and date the form; an unsigned form is not valid. Once the patient has signed the completed form, he or she must receive a legible copy; a photocopy is fine.

Q. Must we submit a claim?

A. It depends. If the beneficiary chooses Option 1, you must file a claim and append an appropriate modifier to the reported item(s) or service(s).

• Modifier GA is defined as “Waiver of Liability Statement Issued as Required by Payer Policy.”
• Modifier GX is defined as “Notice of Liability Issued, Voluntary Under Payer Policy.”

Option 2 applies to situations where Medicare is precluded from paying for the service and the beneficiary does not dispute the point. It is not necessary to file a claim; however, do post the service in your computer system with modifier GY.

If the beneficiary chooses Option 3, no further action is required because you will not provide the services.

Q. What happens if we don’t get a signed ABN form and Medicare denies the claim?

A. Without proof of the beneficiary’s advance acceptance of financial responsibility, you will be required to refund any payment you collected and will not be permitted to collect from the patient.

Q. Is the ABN form used for all Medicare patients?

A. Unfortunately, no. Medicare Advantage (Part C) plans are precluded from using the Medicare ABN form. They are required to provide a determination of benefits in advance of any noncovered services. Each plan will have its own form or other mechanism; check with the plans. RP