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Advanced Beneficiary Notice of NonCoverage. The what, when, why and how of ABN administration – Medicare Part B Authored By : Bobbi L. Andera BSMT, AMT Business / Regulatory Manager – Sanford Laboratories Edited by : Daniel Ingemansen MS

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Advanced beneficiary notice of noncoverage

Advanced Beneficiary Notice of NonCoverage

The what, when, why and how of ABN administration – Medicare Part B

Authored By: Bobbi L. Andera BSMT, AMT

Business / Regulatory Manager – Sanford Laboratories

Edited by: Daniel Ingemansen MS

Business Performance Specialist - Sanford Laboratories


Advanced beneficiary notice of noncoverage1
Advanced Beneficiary Notice of Noncoverage

  • An ABN, or Advanced Beneficiary Notice of Noncoverage, is a notice administered to a Medicare beneficiary for services which Medicare deems to have limited coverage.

  • CMS form: CMS-R-131 (03/11)

  • Services that Medicare reviews are called Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).

    • LCDs and NCDs provide guidance for those administering an ABN

What is an ABN?

Sanford Laboratories updated 07/31/2013


Advanced beneficiary notice of noncoverage2
Advanced Beneficiary Notice of Noncoverage

  • An ABN should be administered anytime a provider orders services which Medicare may not cover.

  • Must be administered before services are provided

  • Medicare may not cover testing for the following reasons:

    • Does not pay for testing based on condition (ICD-9-CM)

    • Frequency

    • Research, experimental or investigational use tests

When should a notice be administered?

Sanford Laboratories updated 07/31/2013


Advanced beneficiary notice of noncoverage3
Advanced Beneficiary Notice of Noncoverage

  • A properly administered ABN allows the provider of services to bill the beneficiary directly if not covered by Medicare.

    • If not completed properly, neither Medicare nor the beneficiary will be held financially responsible.

  • Informs patients of testing ordered, and the estimated cost of tests.

Why is the ABN administered?

Sanford Laboratories updated 07/31/2013


Advanced beneficiary notice of noncoverage4
Advanced Beneficiary Notice of Noncoverage

  • All areas of an ABN must be completed prior to services provided for an ABN to be considered valid by Medicare.

  • Failure to complete all required information will result in an invalid ABN. Neither Medicare nor the beneficiary will be held financially responsible.

How is an ABN administered?

Sanford Laboratories updated 07/31/2013


Advanced beneficiary notice of noncoverage5
Advanced Beneficiary Notice of Noncoverage

  • Medically reviewed tests are located under the NCDs and LCDs tab of our website: www.sanfordlaboratories.org

  • Routine and Screening tests are statutorily excluded. ABN is not required when a routine or screening diagnosis is associated. Refer to the first section of the NCD PDF which lists codes that are never covered.

Step 1: Determine if the test is medically reviewed

Sanford Laboratories updated 07/31/2013


Medically reviewed tests medicare part b
Medically Reviewed Tests– Medicare Part B

  • BNP

  • Cytogenetic Tests

  • Genetic Tests

  • Vitamin D

  • Urine Culture, Bacterial

  • HIV – prognostic

  • HIV – diagnostic

  • Blood Counts

  • PTT

  • PT

  • Serum Iron Studies

  • Collagen Crosslinks

  • Glucose, Blood

  • Hemoglobin A1C/Glycated Protein

  • Thyroid Testing

  • Lipids Testing

  • Digoxin – Therapeutic

  • Alpha-fetoprotein

  • Carcinoembryonic Antigen (CEA)

  • HCG

  • CA 125

  • CA 15-3, CA 27.29

  • Ca 19-9

  • PSA

  • GGT

  • Hepatitis Panel/Acute Panel

  • Fecal Occult Blood Test

  • Urinalysis

Sanford Laboratories updated 07/31/2013


Advanced beneficiary notice of noncoverage6
Advanced Beneficiary Notice of Noncoverage

  • If tests ordered are medically reviewed and the diagnosis is not statutorily excluded, determine if the diagnosis is covered.

    • Diagnosis is covered- an ABN is not required

    • Diagnosis is not covered- an ABN is required

Step 2: Determine if the diagnosis is covered

Sanford Laboratories updated 07/31/2013


Advanced beneficiary notice of noncoverage step 3 completing the abn
Advanced Beneficiary Notice of NoncoverageStep 3: Completing the ABN

  • Form CMS-R-131 (3/11) must be used. Earlier forms are considered invalid. The form number is located on the bottom left hand side of form

Sanford Laboratories updated 07/31/2013


Advanced beneficiary notice of noncoverage step 3 completing the abn1
Advanced Beneficiary Notice of NoncoverageStep 3: Completing the ABN

  • Required Items

    • Patient Name

    • Lab Test Name(s) requiring ABN

    • Reason Medicare may not pay (Select only one)

    • Estimated cost

      • See sanfordlaboratories.org

    • Beneficiary or beneficiary’s representative must choose one and only one option

    • Beneficiary or beneficiary’s representative must sign

    • Beneficiary or beneficiary’s representative must date

  • Beneficiary must receive a copy of ABN

  • NOTE! If the ABN form being used does not have the notifier section populated, you must enter the notifier information in the top portion of the claim (clinic/lab name, address and phone number - this is required)

Sanford Laboratories updated 07/31/2013


Advanced beneficiary notice of noncoverage step 3 completing the abn2
Advanced beneficiary notice of noncoverageStep 3: Completing the ABN

  • Optional areas of an ABN

    • Identification number

      • If you choose to provide an ID number, DO NOT use the beneficiary SSN or Medicare ID number. Use a number that is unique to the patient, such as a registration number or an E number.

Sanford Laboratories updated 07/31/2013


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