If you have Original Medicare and your provider has reason to believe that Medicare will deny coverage for a service because of Medicare’s medical necessity requirements, they should give you an Advance Beneficiary Notice (ABN) to read and sign before they provide care. You will not receive ABNs if you have a Medicare Advantage Plan.
If you receive an ABN from your provider, there are a few things you should ask before choosing whether to sign the ABN or refuse care:
- If your provider thinks the service is medically necessary, ask why you need to sign an ABN. Medicare should pay for most medical services you need, unless the service is specifically excluded from coverage, in which case an ABN is not required.
- Ask your provider if they are willing help you appeal Medicare’s coverage decision by writing a letter justifying your medical need for the service. If your provider refuses to write a letter or help you appeal, you may want to find a different provider.
Know that you can request that your provider submit a bill to Medicare even after you have signed an ABN, to see if Medicare will cover the service. You also have the right to appeal if the service is denied. But keep in mind that you may be responsible for the full cost of your care if you sign an ABN and Medicare denies coverage.
In limited circumstances, you can ask Original Medicare whether or not it will cover a service before you get it, for instance if you need a power wheelchair or very expensive service. Find out if Medicare will give this prior authorization by contacting 1-800-MEDICARE or talking to your provider before you receive the service.