{"id":3842,"date":"2012-08-16T20:41:17","date_gmt":"2012-08-16T20:41:17","guid":{"rendered":"http:\/\/www.medicareadvocacy.org\/?p=3842"},"modified":"2012-08-16T20:55:04","modified_gmt":"2012-08-16T20:55:04","slug":"cms-clarifies-when-the-advance-beneficiary-notice-of-non-coverage-abn-must-be-issued","status":"publish","type":"post","link":"https:\/\/medicareadvocacy.org\/cms-clarifies-when-the-advance-beneficiary-notice-of-non-coverage-abn-must-be-issued\/","title":{"rendered":"CMS Clarifies When the Advance Beneficiary Notice of Non-Coverage (ABN) Must be Issued"},"content":{"rendered":"

August 16, 2012<\/strong><\/p>\n

On June 1, 2012, the Centers for Medicare & Medicaid Services (CMS) issued Transmittal No.R2480CP, which updates its instructions on the issuance of the Advance Beneficiary Notice (ABN), Form CMS-R-131.[1]<\/a>  The changes are effective on September 4, 2012.[2]<\/a>  The new transmittal is part of an ongoing effort by CMS to provide additional information about the use of ABNs. It provides clarification on when an ABN is mandatory and when it is voluntary or not necessary. Additionally, the transmittal updates manual language, brings the ABN process into compliance with the Affordable Care Act (ACA),[3]<\/a> provides a new Quick Glance Guide, and creates additional hypothetical situations for illustration purposes.<\/p>\n

ABNs extend financial liability protections to Medicare beneficiaries when a provider knows or has reason to know that an ordinarily covered Medicare an item or service will not be covered in a particular instance.[4]<\/a> Regardless of who provides the services, the billing entity is always responsible for ensuring that the appropriate ABN is delivered to the beneficiary.[5]<\/a> If a beneficiary has a known legal representative, the ABN must be issued to the representative.  If they do not, CMS may appoint a representative if it is necessary.[6]<\/a><\/p>\n

The ABN is to be provided before the item or service is provided.[7]<\/a> In addition, providers are prohibited from systematically issuing ABNs and must have specific, identifiable reasons for asserting non-coverage through the use of an ABN.[8]<\/a> Providing an ABN that is out of date is inadequate notice.[9]<\/a>  If a provider issues an ABN that is no longer current, he or she is presumed to have known that the services would not be covered and is not able to shift liability to the beneficiary.[10]<\/a>  Use of the most current ABNs may avoid protracted disputes, including litigation by providers seeking to obtain payment from unsuspecting beneficiaries. Providers and suppliers may charge their usual and customary fee for the items or services that it furnishes to the beneficiary if (a) the supplier\/provider furnishes a proper ABN, (b) the beneficiary agrees to pay, and (c) Medicare denies the claim.[11]<\/a><\/p>\n

If a provider fails to issue the ABN or uses an outdated version, the provider risks being held liable for the services or items in question.[12]<\/a>  ABNs inform Medicare beneficiaries in advance that a particular service will not be covered by Medicare.  Beneficiaries can then decide whether to have the service or treatment and whether to appeal to Medicare to challenge the non-coverage.<\/p>\n

The ABN is mandatory for a Medicare-covered item or service when —<\/strong><\/p>\n