UHC Develops “ANN” Form
On October 1, 2012, UnitedHealthCare released an Advance Notice of Non-coverage form (ANN) for use with Medicare Advantage plan members to notify them that a particular service may not be covered by their plan. Similar to Medicare’s Advance Beneficiary Notice (ABN), the form provides three options for the patient to consider and must be completed in its entirety to be considered a valid form.
According to the notification, the form is to be used on a case by case basis when “when the provider has reason to believe that UnitedHealthcare may not provide coverage for a particular item or service.” Patients must be presented with this form prior to the non-covered service if the provider intends to collect from the patient. Claims filed for the non-covered service will include modifier GA to indicate that the patient has received and signed an ANN form specific to the non-covered item or service.
Unlike traditional Medicare, it appears that this form should also be used for items that are known to be non-covered such as refractions and premium IOL services and lenses.
Detailed instructions can be found at: https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/ANN_for_Medicare_Advantage_Members_Instructions.pdf
The actual form template is on the UHC website as a word document.