Advanced Beneficiary Notification (ABN) is required to be given to a beneficiary when the clinicians anticipate that the services being provided are no longer meet Medicare’s medical necessity requirement. The ABN informs the patient of their potential financial obligations to the provider and provides guidance regarding appeal rights. Information regarding ABNs can be found on the CMS website:
As well as in the Medicare Claims Processing Manual:
As of March 1, 2009, the revised Advance Beneficiary Notice of Noncoverage (ABN) (Form CMS-R-131), formerly the “Advance Beneficiary Notice”, will replace the NEMB, the ABN-G, and the ABN-L. The use of these forms will no longer be considered valid notification to beneficiaries.
ABN forms are available for download from the CMS website. It is highly recommended that facilities use the ABN forms on the CMS website as opposed to crafting their own forms. CMS has very strict guidelines on how the forms are to appear and what can and cannot be changed to meet the requirements.
In general, facilities are expected to retain their copy of the ABN for 5 years from discharge/completion of delivery of care when there are no other applicable requirements under State law. Retention is required in all cases, including those cases in which the beneficiary declined the care, refused to choose an option, or refused to sign the notice.
Contractors assume that the beneficiary did not know services were not covered unless there is documentation that the beneficiary was notified. In some cases, the beneficiary may have been given notice in a recent previous claim that a type of care is not covered. More commonly, the facility gives an ABN to the beneficiary alerting them that a particular stay or course of treatment is not covered, or that coverage ended at a particular time.
According to the Medicare Claims Processing Manual:
Under §1879(c) of the Act and 42 CFR 411.404, the beneficiary is held to be liable when it is determined that he or she had prior knowledge that Medicare payment for the service or item would be denied or could reasonably have been expected to have had such knowledge. The most likely reason to find that the beneficiary knew or could reasonably have been expected to know that Medicare would not pay is where, before the item or service was furnished, the provider, practitioner, or supplier notified the beneficiary by properly delivering the approved Advance Beneficiary Notice (ABN), of the certainty or likelihood that Medicare would not pay for the specific service.
The ABN is required to be given to a beneficiary when the clinicians anticipate that the services being provided are no longer meet Medicare’s medical necessity requirement. This form is to be provided to the patient regardless of their financial limitation or the cap exception process. For example, this form would be issued to a patient who has met their goals but wishes to continue therapy and the cap has not yet been met. The form would also be given to the same patient if the cap had been exceeded.
Facilities are required to issue ABNs whenever limitation on liability applies. This typically occurs at three points during a course of treatment, which are initiation, reduction, and termination, also known as “triggering events”. For example:
An initiation is the beginning of a new patient encounter, start of a plan of care, or beginning of treatment. If a notifier believes that certain otherwise covered items or services will be noncovered (e.g. not reasonable and necessary) at initiation, an ABN must be issued prior to the beneficiary receiving the non-covered care.
A reduction occurs when there is a decrease in a component of care (i.e. frequency, duration, etc.). For example, a beneficiary is receiving outpatient physical therapy five days a week and wishes to continue therapy five days; however, the notifier believes that the beneficiary’s therapy goals can be met with only three days of therapy weekly. This reduction in treatment would trigger the requirement for an ABN.
Termination is the discontinuation of certain items or services. An example would be when a physical therapist no longer considers outpatient speech therapy described in a plan of care reasonable and necessary. An ABN would have to be issued prior to the termination of the speech therapy. If the beneficiary wishes to continue receiving noncovered speech therapy treatments upon receiving the ABN, he or she must select Option 1 or 2 on the ABN stating that he or she wants to receive the services and agrees to be financially responsible if Medicare does not pay.
The facility is also required to inform the beneficiary of their rights to an expedited determination. According to CMS, facilities must give notice to Medicare beneficiaries of their right to expedited determinations when their period of covered care ends. Expedited determinations allow beneficiaries to challenge/appeal the facility’s decisions to discharge, whereas the standard appeal process available after a claim is adjudicated allows beneficiaries to dispute payment denials.
Providers should note that this requirement applies to the facility whether the patient is being discharged or remaining in the facility at the termination of SNF level care (when the beneficiary remains technically eligible).
According to the Medicare Claims Processing Manual, basic delivery requirements of the ABN are as follows:
The notifier should hand-deliver the ABN to the beneficiary or authorized representative. (Where hand-delivery is impossible, e.g., in furnishing items and services by telephone order, mail order, over the internet, etc., ABNs still need to be executed in advance of furnishing the item or service, e.g., by mail, fax, using an online form) Delivery is the notifier’s responsibility. The contractor will consider delivery of an ABN by a notifier’s staff or employees to be delivery by the notifier. If the beneficiary alleges non-receipt of notice and the notifier cannot show that notice was received by the beneficiary, the contractor will not find that the beneficiary knew or could reasonably have been expected to know that Medicare would not pay; i.e., it will hold the notifier liable and the beneficiary not liable.
The ABN must be prepared with an original and at least one copy. The notifier must retain the original and give the copy to the beneficiary or authorized representative. (In a case where the notifier that gives an ABN is not the entity which ultimately bills Medicare for the item or service, e.g., when a physician draws a test specimen and sends it to a laboratory for testing, the notifier should give a copy of the signed ABN to the entity which ultimately bills Medicare.) The copy is given to the beneficiary immediately after the beneficiary signs it. Legible duplicates (carbons, etc.), fax copies, electronically scanned copies, or photocopies will suffice. This is a fraud and abuse prevention measure.
Facilities should use caution, as the contractor will not consider a telephone notice to a beneficiary sufficient evidence of proper notice unless the content of the telephone contact can be verified. If the facility follows-up the telephone notice with a mailed notice and the beneficiary signs a written notice accepting responsibility for payment, the contractor will accept that the time of the telephone notice was the actual time of ABN delivery.
It should also go without saying that the ABN must be issued to a competent person who is able to read and understand the information on the form. In the case where this is not possible, the facility should refer to the Medicare Claims Processing Manual for further instruction.