Getting Paid: How to Complete the ABN Form

The Advance Beneficiary Notice of Noncoverage (ABN)—also known as a waiver of liability or Medicare waiver—that you ask Medicare beneficiaries to sign enables you to legally bill the beneficiary for services that Medicare might not cover. As such, it’s a document that may prove crucial to reimbursement for lab services. To transfer potential financial liability to the beneficiary, however, providers must properly complete the ABN and deliver the notice before providing the service or item they seek to bill the beneficiary for. But for all the ABN’s value in ensuring positive payment outcomes, completing the form can be so complex that some labs decide not to make it part of their billing process. Here’s a primer to help you navigate the intricacies of ABN form completion.

The ABN Form

The first challenge is to ensure you’re using the right version of the ABN. 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 appropriate federal OMB Number (0938-0566) and CMS-R-131.

Because this is an approved form, no changes can be made unless permitted by accompanying instructions. A noteworthy previous comment indicated that form would allow pre-printing of laboratory key information and denial reasons that the “L” form currently displays.

How to Complete the ABN Form

Centers for Medicare & Medicaid Services (CMS) guidance provides instruction on completing the ABN form. (We’ve included a sample laboratory form.) It says ABNs must be reproduced on a single page, either letter or legal-size, with additional space allowed for each blank needing completion when a legal-size page is used. There are 10 blanks for completion in this notice, labeled from (A) through (J):

• CMS recommends that notifiers remove 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. (Note that 10-point font can be used in blanks when detailed information must be given and is otherwise difficult to fit in the allowed space.)
• The notifier must also insert the blank (D) header information into all of the blanks labeled (D) within the Option Box section, Blank (G)
• One of the check boxes in the Option Box section, Blank (G), must be selected by the beneficiary or his/her representative
• Blank (I) should be a cursive signature, with printed annotation if needed to be understood
• An attachment is allowed if all services can’t be identified on one page as long as the attachment is noted on the first page of the ABN.

CMS states that the form can’t be altered to accommodate other languages due to the OMB approval requirement. For other languages, verbal assistance “may be” provided. Any assistance should be documented in the Additional Information section of the form.

The Beneficiary’s Options

Three options are provided in a box in section G for services listed in section 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 items or services and requires the notifier 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 that 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 his or her representative must choose only one of the three options listed in Blank (G). Unless otherwise instructed to do so, the notifier must not decide for the beneficiary which of the three checkboxes to select. Pre-selection of an option by the notifier invalidates the notice. However, at the beneficiary’s request, notifiers may enter the beneficiary’s selection if he or she is physically unable to do so. In such cases, notifiers 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 notifier 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.”

The ABN Header

A provider may place a logo (for example, typing, handwriting, pre-printing, label) at the top of the ABN form that, at a minimum, identifies the name, address, telephone number and, when appropriate, the TTY number. The latter information may be part of the logo. This information provides the beneficiary with contact information if questions arise. The word “notifier” may be completely eliminated from the form. This allows room for the notifier information to spread across the top of the form.

Another change allows more than one entity to be identified. For example, the ordering physician and the laboratory provider may both be identified in the header. However, it must be clear which is which in case the beneficiary has questions.

Patient Name

First and last name should be entered as well as the middle initial if it’s indicated on the Medicare card. If the initial is missing or the name is misspelled, the form is not invalidated as long as the beneficiary or representative recognizes the name on the form.

Identification Number

Another change is that an ID number is optional. If a number isn’t indicated, the form is not invalidated. Ironically, the Medicare number will no longer be recognized. Perhaps, this is part of the proposed Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirement that beneficiaries also have an ID number. An internal filing number created by the notifier, such as a medical record number, may be used. Medicare Health Insurance Claim Numbers (HICNs), Medicare Beneficiary Identifiers (MBIs), or Social Security numbers should not appear on the notice.

Items and Services

Wording for this part of the form may vary. For example, laboratory test(s), test(s), or procedure(s) may be used. Also, the (s) is optional. It may be included and crossed out when only one test is listed or it may be added if multiple services are listed.

Tests must be clearly identified. If technical language must be used, the service must be verbally explained.

Reasons for Non-Payment

The former laboratory reasons for potential non-coverage still apply. Each service must be linked to a specific service/test. Three commonly used reasons for non-coverage are:

• “Medicare does not pay for this test for your condition.”
• “Medicare does not pay for this test as often as this (denied as too frequent).”
• “Medicare does not pay for experimental or research use tests.

If the beneficiary decides to not receive all services on the ABN, the denied services and their related information may be crossed out. If the beneficiary can’t make a decision, this should be annotated.

Estimated Cost

CMS will be “flexible” in defining a good faith estimate of cost for the beneficiary. This especially applies when the ordering and providing entities are different. In general, the estimate should be within $100 or 25 percent of the actual costs, whichever is greater; however, an estimate that exceeds the actual cost substantially would generally still be acceptable, since the beneficiary would not be harmed if the actual costs were less than predicted.

Signature Box

Once the beneficiary reviews and understands the information contained in the ABN, the Signature Box is to be completed by the beneficiary (or representative). This box cannot be completed in advance of the rest of the notice.

Other Information

Additional information may be submitted below the Option Boxes. For example, the beneficiary may be guided to let the ordering provider know if a service is not opted or to supply additional insurance information. More information on dual eligible beneficiaries may be found at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo.