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, but not if you have a Medicare Advantage 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, 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 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:
- 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.