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  • How to Use the Advance Beneficiary Notice

    Newest Version Mandatory as of June 30, 2023

    The Centers for Medicare and Medicaid Services (CMS) has approved the most current version of the Advance Beneficiary Notice (ABN). Implementation of the new form is mandatory as of June 30, 2023. The updated ABN has the new expiration date of January 1, 2026 in the bottom left corner, however no other changes are present. As the form is now accessible, it would be appropriate to begin using.

    When you need to get an ABN

    You should obtain a signed ABN from a Medicare Part B patient when you’re not sure about frequency or diagnosis coverage. When determining if Medicare Part B covers a service, you should first look for a policy.

    Cases where coverage is unclear include:

    • Uncovered diagnosis code;
    • An oculofacial procedure that may be deemed cosmetic rather than medically necessary;
    • A service provided more frequently than CMS covers.

    Services considered statutorily excluded do not require a signed ABN. These include:

    • Refraction services;
    • Routine vision care;
    • Cosmetic surgeries (including LASIK); and
    • Off-label/noncovered services. 

    What the ABN does

    In situations where Medicare payment is expected to be denied, the ABN form formally tells patients they may be responsible for the service if Medicare does not pay. Always educate the patient on why the service may not be covered. 

    The form also documents which of three options the patient desires.

    Option 1: Receive the service as outlined, bill to Medicare.

    • The provider may ask to be paid now, but also agrees to bill Medicare for an official decision on payment, sent to the patient on a Medicare Summary Notice (MSN).
    • The patient consents to payment if Medicare doesn’t pay but can appeal Medicare’s decision by following the directions on the MSN.
    • If Medicare does pay, the provider refunds any initial patient payments, less co-pays or deductibles.

    Option 2: Receive the service as outlined, do not bill to Medicare. The patient pays.

    • The provider may ask to be paid now and does not bill Medicare.
    • The patient cannot appeal, since the practice did not bill Medicare.

    Option 3: Decline the service as outlined.

    • The provider does not perform the service.
    • The patient has no payment obligation and cannot appeal to see if Medicare would pay.

    Best Practices

    1. Don’t alter the ABN in any way, otherwise Medicare may not accept it.
    2. Fill out each section, including the practice and patient information.
    3. Have the patient sign the form once s/he makes a decision.
    4. To ensure your claim is processed correctly, append modifier -GA to the CPT code. Modifier -GA notifies Medicare that you obtained a signed ABN. Without the modifier, Medicare will notify the patient that they are not responsible for payment of the service; the physician should have provided a statement of possible noncoverage.
    5. Once you implement the new version, make sure to remove all other versions from the practice. CMS will only accept the current version will be accepted.
    6. Do not apply this form to other payers; they may have their own forms or require your practice to create your own. Confirm with each payer; there is no consistency.