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 Noncoverage
What is an ABN?
• 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
Sanford Laboratories
updated 07/31/2013
Advanced Beneficiary
Notice of Noncoverage
When should a notice
be administered?
• 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
Sanford Laboratories
updated 07/31/2013
Advanced Beneficiary
Notice of Noncoverage
Why is the ABN
administered?
• 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.
Sanford Laboratories
updated 07/31/2013
Advanced Beneficiary
Notice of Noncoverage
How is an ABN
administered?
• 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.
Sanford Laboratories
updated 07/31/2013
Advanced Beneficiary
Notice of Noncoverage
Step 1: Determine if
the test is medically
reviewed
• 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.
Sanford Laboratories
updated 07/31/2013
Medically Reviewed Tests– Medicare Part B
•
•
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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
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•
•
•
•
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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
• If tests ordered are
Advanced Beneficiary
medically reviewed and the
Notice of Noncoverage
diagnosis
is
not
statutorily
Step 2:
excluded,
determine
if
the
Determine if the
diagnosis is covered.
diagnosis is
– Diagnosis is covered- an ABN
covered
is not required
– Diagnosis is not covered- an
ABN is required
Sanford Laboratories
updated 07/31/2013
Advanced Beneficiary
Notice of Noncoverage
Step 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
•
Required Items
– Patient Name
– Lab Test Name(s) requiring ABN
– Reason Medicare may not pay
(Select only one)
– Estimated cost
Step 3: Completing
the ABN
•
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 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