An Advance Beneficiary Notice (ABN), also known as a waiver of liability, is a notice you should receive when a provider or supplier offers you a service or item they believe Medicare will not cover. ABNs only apply if you have Original Medicare, not if you are in a Medicare Advantage private health plan. The ABN may look slightly different, depending on what type of provider you received it from.
Providers must give you an ABN when the service or item could be covered by Medicare, but the provider expects that Medicare will not find the care to be medically necessary and will, therefore, deny coverage. The ABN must list the reason why the provider doubts Medicare will cover care. For example, an ABN might say, “Medicare only pays for this test once every three years.” Providers are not required to give you an ABN for services or items that are never covered by Medicare, such as hearing aids.
The ABN serves as warning that Medicare may not pay for the care your provider recommends. However, it is still possible that Medicare will approve coverage. To get an official decision from Medicare, you must first receive the care and sign the ABN form, agreeing to pay for it yourself if Medicare rejects coverage.
Additionally, to have a chance of receiving Medicare coverage, you must select Option 1 on the ABN form. Selecting this option requires your provider to bill Medicare after providing you with the service or item. If you fail to select Option 1 on the ABN, you have no chance of Medicare coverage because your doctor is not required to submit the claim.
ABNs and Appeals
When your Medicare Summary Notice (MSN) shows that Medicare has denied payment for a service or item, you should file an appeal. Receiving an ABN does not prevent you from filing an appeal.
Medicare has rules about when you should receive an ABN and how it should look. If these rules are not followed, you may not be responsible for the cost of the care. However, you will have to file an appeal to prove this.
You might not be responsible for charges if the ABN:
- Is difficult to read or hard to understand.
- Is given by the provider (except a lab) to every patient with no reason to believe claims may be denied.
- Does not list the actual service provided or is signed after the date the service was provided.
- Is given to you during an emergency or is given to you just prior to receiving a service (i.e. on the way into the MRI machine).
Another reason you may not be responsible for the charges is if an ABN was not provided when it should have been. You may not need to pay for care if you meet all of the following requirements:
- You did not receive an ABN from your provider before you were given the service or item;
- Your provider had reason to believe your service or item would not be covered by Medicare;
- Your item or service is not specifically excluded from Medicare coverage; and
- Medicare has denied coverage for your item or service.