ABN Requirements

Medicare often covers the cost of such patient expenses as medical treatments, health-related services and medical supplies, but it can exclude select medical costs. Medicare requires medical providers to issue to patients (or their legally authorized medical representative, where applicable) an advance beneficiary notice (ABN) before performing any service the provider expects Medicare might exclude for payment. Upon effective issuance of an ABN, the patient assumes financial responsibility for any service covered in the ABN. Medical providers required to issue ABNs include doctors, hospitals, laboratories, practitioners and medical suppliers.

Mandatory Issuance

• Medicare requires issuance of an ABN whenever the medical service provider expects Medicare will not pay for a medical treatment, service or supply. Providers make ruling based on Medicare Program standards, which outline reasonable and necessary services. Medicare can exclude payment for such items and services as cosmetic surgery, eye examinations, tests related to screening procedures, chiropractic services, self-administered medications (typically noninjected medications) and immunizations.

Routine Notice Violations

• Medical providers must have a reasonable grounds for issuing an ABN. Although Medicare does not evaluate providers based on volume of ABNs issued, providers cannot issue ABNs on a routine basis simply to cover legal risks. Medicare does not deem an ABN reasonable when issued for services that are typically exclusions.

Delivery

• Medicare requires medical providers deliver ABNs in writing, with enough advanced notice for a patient to consider all options available. In the case of emergency room treatments, Medicare only requires issuance of an ABN when a patient's medical condition is stable. Medicare advises medical providers to deliver ABNs in person when possible, explaining the notice completely and answering all questions posed by the patient. Effective notification requires comprehension of the document by recipients. When circumstances do not allow personal delivery of an ABN, medical providers can deliver by mail, fax machine or email. When not delivered in person, ABN deliveries must be documented in patient records. In the event a patient disputes an ABN not delivered in person, Medicare can rule the ABN ineffective.

ABN Forms

• Medicare requires two copies of each ABN form, one for the records of the medical provider and the other for the patient. Providers can attach additional information, such as service information, but the ABN itself cannot exceed one page. All attachments must include a patient's name and identification number. Medicare requires providers to complete information in all blanks of the ABN. Form information must include the date, services the provider expects Medicare to exclude, the reason for expected exclusion and estimated cost associated with the service. The medical provider must obtain the signature of the patient or representative and provide a copy of the dated and signed ABN for the patient. Providers that fail to use correct ABN forms can face legal liability for services provided.