- An advance beneficiary notice of noncoverage (ABN) lets you know when Medicare may not cover an item or service.
- You must respond to an ABN in one of three ways.
- If a claim has been denied for Medicare coverage, you have the right to appeal the decision.
Sometimes, medical items and services are not covered by your Medicare plan. When this happens, you will receive a notice called an Advance Beneficiary Notice of Noncoverage (ABN). An ABN is sent by a doctor, other health professional, or a medical supplier.
We’ll discuss what information is provided in these notices, what to do when you get one, how to appeal a claim denial, and more.
An Advance Beneficiary Notice of Noncoverage (ABN) is a liability waiver form that is given when a healthcare provider or medical supply company thinks or knows Medicare will not cover something. An ABN will explain:
- the goods or services that Medicare will not cover
- the estimated cost of each item and service that Medicare will not cover
- However, an ABN is not required for items or services that Medicare never covers. Some examples would include:
- routine foot care
- hearing aids
- cosmetic surgery
A full list of items and services not covered by Medicare parts A and B can be found here.
There are a few types of ABNs that relate to different types of services:
- Skilled Nursing Facility Advance Beneficiary Notice
- Hospital Issued Notice of Noncoverage
- Fee-for-Service Advance Beneficiary Notice
Skilled Nursing Facility Advance Beneficiary Notice
A skilled nursing facility may send you a Skilled Nursing Facility ABN if there is a chance that your care or a long-term stay in a facility will not be covered by Medicare Part A.
This type of ABN may also be issued if your stay is considered custodial care. Custodial care refers to help with activities of daily living. These can include bathing, dressing, and help with meals.
Hospital Issued Notice of Noncoverage
A Hospital Issued Notice of Noncoverage is sent when either all or a portion of your inpatient hospital stay may not be covered by Medicare Part A. The notice will explain why Medicare may not pay and provide an estimate of what you will owe if you continue to receive the services.
Fee-for-Service Advance Beneficiary Notice
If you have received an ABN, you must respond to confirm how you’d like to proceed. There are three different options to choose from:
- You want to continue receiving the items or services that may not be covered by your Medicare plan. In this case, you may have to pay up front initially, but the provider will still submit a claim to Medicare. If the claim is denied, you can appeal. If the claim is approved, Medicare will refund the money that you paid.
- You want to continue receiving the items or services that may not be covered but you do not want to submit a claim to Medicare. You will most likely have to pay out of pocket for the services and there is no option to appeal the decision because you did not submit a claim.
- You don’t want the services or items that may not be covered. By opting out of the services or items, you won’t be responsible for any costs listed in the notice.
By signing an ABN, you are agreeing to the fees that may come with the items and services you are receiving. You are also accepting responsibility to pay for the item or service, even if Medicare denies the claim and will not reimburse you.
Ask any questions you have about the service you’re receiving and how much it will cost. That way, there are no surprises if or when you receive a bill.
If your claim is denied by Medicare, you can file an appeal. Here are a few things you need to know:
- You must file the appeal within 120 days of receiving your Medicare summary notice, which will have your appeal information on it.
- To start the appeal process, fill out a Redetermination Request Form and send it to the company that submits claims to Medicare. You should be able to find this information on the Medicare summary notice.
- You can submit a written appeal request to the company that handles claims for Medicare. Provide your name and address, Medicare number, the items or services you would like to appeal, an explanation of why it should be covered, and any other information that you think may help your case.
Once you have filed an appeal, you should get a decision within 60 days of your request being received.
Other helpful resources
- Medicare ABN tutorial. This is an interactive tutorial that will help you understand how an ABN works.
- General Medicare information. You can look here for general information about Medicare plans and ABNs.
- Medicare parts A and B exclusion list. Wondering if something is covered under your Medicare plan? Check here for items and services that are not covered.
You will receive an ABN if a hospital, healthcare provider, or medical supplier thinks that Medicare may not cover an item or service that you have received. You can appeal a claim that has been denied for Medicare coverage. Ultimately, you may need to pay for the service out of pocket if you agree to accept it after receiving an ABN.
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