Be Sure to Use New ABN Form, Starting August 31

In case you haven’t gotten the word, the federal Office of Management and Budget (OMB) has approved the Advance Beneficiary Notice of Noncoverage (ABN) Form for renewal. As of August 31, 2022, labs and other providers must use the new ABN labeled with the appropriate federal OMB Number (0938-0566) and CMS-R-131 to ensure they can bill Medicare beneficiaries for any lab tests or other services that Medicare doesn’t cover.

The ABN Form

Independent labs, physicians, practitioners, home health agencies, hospices, and suppliers rely on the ABN, aka waiver of liability or Medicare waiver, to transfer financial liability to Medicare beneficiaries for services that Medicare may not cover. As such, the ABN is a document that may prove crucial to reimbursement for lab services. However, the form undergoes periodic review and revision and it’s essential to use the right form.

The renewed form includes no substantive changes from the previous version, with one exception: The expiration date listed on the bottom is June 30, 2023. So, beginning August 31, 2022, only ABNs carrying that expiration date will be recognized as valid. 

Executing the New ABN

Also unchanged is the CMS guidance providing instruction on properly completing the ABN form. As before, ABNs must be reproduced on a single page, either letter or legal-size, and include 10 blanks, labeled from (A) through (J). CMS recommends removing the lettering labels from the blanks before issuing the ABN to beneficiaries. Blanks (A)-(F) and blank (H) may be completed before delivering the notice, as appropriate. Entries in the blanks may be typed or handwritten, but should be large enough (i.e., approximately 12-point font) to allow ease in reading.

The key section is Blank (G) in which beneficiaries select among three options (which are listed and described in Blank (D)):

Option 1. I want the (D)_________listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following directions on the MSN. If Medicare does pay, you will refund any payments I made you, less co-pays and deductibles.

This option allows the beneficiary to receive the lab tests or services and requires the lab or other notifying provider (which, for simplicity’s sake, we’ll refer to as the “lab”) to submit a claim to Medicare. This will result in a payment decision that can be appealed.

Option 2. I want the (D)_________listed above, but do not bill Medicare. You may ask to be paid now, as I am responsible for payment. I cannot appeal if Medicare is not billed.

This option allows the beneficiary to receive the non-covered items and/or services and pay for them out of pocket. No claim will be filed and Medicare will not be billed. Thus, there are no appeal rights associated with this option.

Option 3. I don’t want the (D)_________listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

This option means the beneficiary does not want the care in question. By checking this box, the beneficiary understands that no additional care will be provided; thus, there are no appeal rights associated with this option.

The beneficiary or their representative must choose only one option listed in Blank (G). Unless otherwise instructed to do so, the lab must not decide for the beneficiary which of the three checkboxes to select. Such pre-selection of an option invalidates the notice. However, at the beneficiary’s request, labs may enter the beneficiary’s selection if they’re physically unable to do so. In such cases, labs must annotate the notice accordingly.

If there are multiple items or services listed in Blank (D) and the beneficiary wants to receive some, but not all of them, the lab can use more than one ABN by furnishing an additional ABN listing the items/services the beneficiary wishes to receive with the corresponding option.

If the beneficiary cannot or will not make a choice, the notice should be annotated. Example: “beneficiary refused to choose an option.”

_________________________________________________________________________________________________________________________________________________

Diana W. Voorhees, M.A., CLS, MT, SH, CLCP, CPCO, is principal in DV & Associates, Inc., Salt Lake City, UT, which makes no representation, guarantee, or warranty, expressed or implied, that the information provided is free of error, and will bear no responsibility or liability for results or consequences of its use.