We are often asked if it is ok to either not bill Medicare for a service provided to a patient or to bill the patient instead ? Great questions with a lot of guidelines.
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. The ABN is issued in order to transfer potential financial liability to the Medicare beneficiary in certain instances. Guidelines for issuing the ABN can be found beginning in Section 50 in the Medicare Claims Processing Manual, 100-4, Chapter 30 (PDF).
An ABN form is available by CMS at the link attached. The form is subject to public comment and re-approval every 3 years so having the most recent version is very important. There are tutorials, instructions, and forms in both English and Spanish for your use.
The ABN must be reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed. The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. Employees or subcontractors of the notifier may deliver the ABN. ABNs are never required in emergency or urgent care situations. Once all blanks are completed and the form is signed, a copy is given to the beneficiary or representative. In all cases, the notifier must retain a copy of the ABN delivered to the beneficiary on file.
The ABN may also be used to provide notification of financial liability for items or services that Medicare never covers. When the ABN is used in this way, it is not necessary for the beneficiary to choose an option box or sign the notice. CMS has issued detailed instructions on the use of the ABN in its on-line Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 30, §50 . Related policies on billing and coding of claims, as well as coverage determinations, are found elsewhere in the CMS manual system or CMS website .
On the billing side is a modifier we need to submit with the initial claim to signify the ABN is on file and the patient will then be responsible for the balance - GA Waiver of Liability Statement Issued as Required by Payer Policy, Individual Case Report when you issue a mandatory ABN for a service as required and it is on file. You do not need to submit a copy of the ABN, but you must have it available on request. The –GA modifier is used when both covered and noncovered services appear on an ABN-related claim.
Read the full list of guidelines on the CMS website.