Medical Billing ServicesRevenue Cycle Management (RCM)

Advance Beneficiary Notice of Non-coverage (ABN) Updates

Changes to the Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is issued by providers (including independent laboratories, home health agencies, and hospices), physicians, practitioners, and suppliers to Original Medicare (fee for service – FFS) beneficiaries in situations where Medicare payment is expected to be denied.

Skilled nursing facilities (SNFs) issue the ABN to transfer potential financial liability for items/services expected to be denied under Medicare Part B only.

The ABN, Form CMS-R-131, and instructions have been approved by the Office of Management and Budget (OMB) for renewal. Due to COVID-19 concerns, CMS has expanded the deadline for use of the renewed ABN, Form CMS-R-131 (exp. 6/30/2023). At this time, the renewed ABN will be mandatory for use on 1/1/2021. The renewed form may be implemented prior to the mandatory deadline.

ABN modifier

Waiver of Liability Statement Issued as Required by Payer Policy. This modifier indicates that an ABN is on file and allows the provider to bill the patient if not covered by Medicare. automatically assign the beneficiary liability.

ABN Revisions

Overview

The ABN is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case. “Notifiers” include:

  • Physicians, providers (including institutional providers like outpatient hospitals), practitioners, and suppliers paid under Part B (including independent laboratories);
  • Hospice providers and religious non-medical health care institutions (RNHCIs) paid exclusively under Part A; and
  • Home health agencies (HHAs) providing care under Part A or Part B.

Revisions

The ABN is a formal information collection subject to approval by the Executive Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (PRA).

The notice is subject to public comment and re-approval every 3 years. With the latest PRA submission, a change has been made to the ABN. In accordance with Title 18 of the Social Security Act, guidelines for Dual Eligible beneficiaries have been added to the ABN form instructions.

ABN Forms

ABN Instructions, Guidelines, and Other Resources

CMS recommends that notifiers remove the lettering labels from the blanks before issuing the ABN to beneficiaries.

Once the claim is adjudicated by both Medicare and Medicaid, providers may only charge the patient in the following circumstances:

  • If the beneficiary has QMB coverage without full Medicaid coverage, the ABN could allow the provider to shift financial liability to the beneficiary per Medicare policy.
  • If the beneficiary has full Medicaid coverage and Medicaid denies the claim (or will not pay because the provider does not participate in Medicaid), the ABN could allow the provider to shift financial liability to the beneficiary per Medicare policy, subject to any state laws that limit beneficiary liability.

If you have any questions regarding the ABN can be submitted at: https://appeals.lmi.org/

References:

CMS Medical General Information

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