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New ABN Form

CMS issues the Advance Beneficiary Notice of Noncoverage (ABN) for you to use to notify your Medicare patients when you believe an item or service may not be covered. This form has been updated and changed several times, with the most recent version being dated 03/08.

Because this is an official Office of Management and Budget document, CMS is required to review the form and make any necessary changes every three years. The new version is dated 03/11, and its use is mandatory by November 2011. There are no changes to the form, other than some minor font changes and, of course, the versions date at the bottom. Nonetheless, you must replace your old 03/08 forms with the 03/11 version.

There were no changes to the instructions about how to complete the form. There were changes to the Medicare Claims Processing Manual (MCPM) Chapter 30, §50, which addresses the ABN and its use. For the most part, these are helpful clarifications. Here are a few of the high points:

· A new discussion about when an ABN is mandatory or voluntary.

  • Mandatory reasons include statutory exclusions, including “not reasonable and necessary” (e.g. not medically necessary) and “supplier number requirements not met” (i.e. the optical dispensary is not a Medicare supplier).
  • Voluntary reasons include statutorily excluded items and services, such as routine eye care.

· The MCPM states that the ABN “can be issued voluntarily in place of the Notice of Exclusion from Medicare Benefits (NEMB).” It does not say the ABN form must be used in lieu of the NEMB form.

· The MCPM reiterates that an ABN must be obtained prior to providing services, must be personally signed and dated by the beneficiary or his/her representative, and that the beneficiary must personally select an option.

· The ABN form is approved for Medicare fee-for-service only, not Medicare Advantage plans.

· The prohibition against issuing blanket ABNs still stands. An ABN must be specific as to the items or services being provided and the reason non-coverage is expected.

· There is also a specific instruction that “ABNs cannot be used to shift liability for an item or service that is described on the ABN as being “better” or “higher quality” on an ABN.”

The MCPM may be accessed at http://www.cms.gov/manuals/downloads/clm104c30.pdf.

The ABN forms (English and Spanish) may be accessed at http://www.cms.gov/BNI/02_ABN.asp

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