An Advance Beneficiary Notice (ABN), also known as a "waiver of liability," is a notice that suppliers and other medical providers are required to give you when they offer you services or items that they know or have reason to believe Medicare will determine to be medically unnecessary for you, and therefore, will not pay for.
Providers are not required to give you an ABN for services or items explicitly excluded from Medicare coverage (items that are never covered by Medicare even if medically necessary, such as hearing aids). In addition, ABNs only apply if you are in Original Medicare, not if you are in a Medicare private health plan (HMO, PPO or PFFS).
If you do not get an ABN to sign before you get the service or item from your provider, it is not specifically excluded from coverage, and Medicare does not pay for it, then you do not have to pay for it. You may need to file an appeal to show that you should not have to pay.
If the provider does give you an ABN that you sign before you get the service or item, and Medicare does not pay for it, then you will have to pay your provider for it.
There will be an option on the ABN to check whether or not you want your doctor to submit a claim to Medicare for the service. You should always select that you want your doctor to submit the claim to Medicare. If you do not, your doctor is not required to submit the claim. You should check this option, because Medicare may still pay for the services after all.
If you sign an ABN but ask your doctor to bill Medicare, and Medicare then denies coverage, you can always appeal.
In addition, you might not be liable for charges if you think the ABN is invalid for the following reasons:
- It is illegible or the font is small (less than 12 point) or hard to read.
- The provider did not use the official CMS ABN form.
- The provider overuses ABNs (issues them with no reason to believe claims may be denied.) Note: Labs may issue ABNs even if there is no reason to believe the claims may be denied.
- The ABN does not list the actual service rendered.
- The form is more than one year old.
- The form is signed after the date the service was provided.
- The form is given to someone that cannot understand it.
- The form is given to someone in an emergency.
- The form is given just prior to getting service (i.e., on their way into the MRI machine).
If you signed an ABN and Medicare is refusing to pay for your care, but you believe the ABN is invalid, you should appeal Medicare's denial with a letter specifying why the ABN is invalid. If the ABN is deemed invalid, the provider becomes responsible for the cost of the services rendered.
In limited circumstances, when you have received an ABN for certain very expensive, non-urgent services, you or your doctor can request prior determination to find out whether Medicare will pay for the service before you receive it.