For
Providers of Health Care Items and Services
Completion of the Advance Beneficiary Notice
(CMS-R-131-G)
Upon final OMB approval
of the Advance Beneficiary Notice (ABN), complete
instructions will be formally published in the Medicare
Carriers Manual, the Medicare Intermediary Manual, and
relevant Provider Manuals. The manual instructions will
be the official Medicare program promulgation of policy
and procedures that providers (viz., physicians,
practitioners, suppliers, and providers under Parts A
and B of Medicare) and Medicare carriers and fiscal
intermediaries are to follow with respect to ABNs.
Header of ABN--
Header top--Put
your (provider’s) name, address and telephone
number at the top of the page of the notice;
including your logo (if any).
“Patient name”
Line--Enter the name of the patient; do not
substitute the name of an authorized
representative.
“Medicare # (HICN)
Line--Enter the patient’s Medicare health
insurance claim number.
Body of ABN--
In the section
beginning “We expect that Medicare will not
pay for the item(s) or service(s) …”, in the
first box “Items or Services:”, specify the
health care items or services for which you
expect Medicare will not pay. The items or
services at issue must be described in
sufficient detail so that the patient can
understand precisely what items or services may
not be furnished. In the second box
“Because:”, give the specific reason why you
expect Medicare to deny payment. The reason(s)
must be sufficiently specific to allow the
patient to understand the basis for your
expectation that Medicare will deny payment,
and, if necessary, to gather evidence to the
contrary in support of the coverage of such
items or services. You may customize these two
boxes for your own use; any pre-printing should
be in at least 12 point Arial or Arial Narrow
font or a similarly readable font.
“Estimated
Cost” Line--You may provide the patient with
an estimated cost of the items and/or services.
Options 1 & 2
Boxes--Have the patient select an option.
In the “Date”
blank, the patient, or person acting on his or
her behalf, enters the date on which he or she
signed the ABN. In the “Signature of patient
…” blank, the patient, or person acting on
his behalf, must sign his or her name.
Disclosure—
According to the
Paperwork Reduction Act of 1995, no persons are required
to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB
control number for this information collection is
0938-0566. The time required to complete this
information collection is estimated to average 5 minutes
per response, including the time to review instructions,
search existing data resources, and gather the data
needed, and complete and review the information
collection. If you have any comments concerning the
accuracy of the time estimate(s) or suggestions for
improving this form, please write to: HCFA, 7500
Security Boulevard, N2-14-26, Baltimore, Maryland
21244-1850.
