Advance Beneficiary Notice (ABN)

An Advance Beneficiary Notice (ABN), also known as a Waiver of Liability, is a notice a provider should give you before you receive a service if, based on Medicare coverage rules, your provider has reason to believe Medicare will not pay for the service. You may receive an ABN if you have Original Medicare Original Medicare Original Medicare, also known as Traditional Medicare, is the fee-for-service health insurance program offered through the federal government, which pays providers directly for the services you receive. Almost all doctors and hospitals in the U.S. accept Original Medicare. , but not if you have a Medicare Advantage Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). Plan. The ABN may look different, depending on the type of provider who gives it to you.

The ABN allows you to decide whether to get the care in question and to accept financial responsibility for the service (pay for the service out-of-pocket) if Medicare denies payment. The notice must list the reason why the provider believes Medicare will deny payment. 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. Note that your providers are not permitted to give an ABN all the time, or to have a blanket ABN policy.

While the ABN serves as a warning that Medicare may not pay for the care your provider recommends, it is possible that Medicare will pay for the service. To get an official decision from Medicare, you must first sign the ABN, agreeing to pay if Medicare does not, and receive the care. Make sure you request that your provider bills Medicare for the service before billing you (the ABN may have a place on the form where you can elect this option). Otherwise, your provider is not required to submit the Claim Claim A claim is a bill that health care providers submit to Medicare to ask for payment for services you received. Medicare Part A and Part B claims are processed by Medicare Administrative Contractors (MACs). Medicare Advantage Plan and Part D plan claims are processed by those private plans. See also: Medicare Administrative Contractor (MAC) and Durable Medical Equipment Medicare Administrative Contractor (DME MAC). , and Medicare will not provide coverage.

ABNs and appeals

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 may have to file an Appeal Appeal An appeal is a formal request for review if you disagree with an official health care coverage or payment decision made by a Medicare Advantage Plan, a Medicare private drug plan (Part D), or Original Medicare. Federal regulations and law specify appeals deadlines, processes for handling appeals, what information must be included in a decision, and the levels of review in the appeals process. to prove this.
When your Medicare Summary Notice (MSN) shows that Medicare has denied payment for a service or item, you can choose to file an appeal. Remember, receiving an ABN does not prevent you from filing an appeal, as long as Medicare was billed.

You may not be responsible for denied 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 specific reason as to why a claim 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 (for instance, immediately before an MRI)

You also may not be responsible for denied charges 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:

1. You did not receive an ABN from your provider before you were given the service or item;
2. Your provider had reason to believe your service or item would not be covered by Medicare;
3. Your item or service is not specifically excluded from Medicare coverage; and
4. Medicare has denied coverage for your item or service.