Advance Beneficiary Notices and Appeals: What do you need to know?

What is an Advance Beneficiary Notice (ABN)? If you have Original Medicare and your doctor or health care provider think that Medicare will not pay for certain items or services that you got, you may receive an ABN.

ABN

An ABN is required to be mailed out when Medicare never covers the items or services that you are receiving. The ABN, also known as a waiver of liability, is a notice that allows you to decide if you are going to receive the care in question and assume the financial responsibility for the service or item if Medicare denies payment. The notice will list the reason why the provider believes Medicare will deny the payment.

While an ABN is a warning to let you know that Medicare may not pay for the care your provider is recommending, it is possible that Medicare may still pay for the service. In order to get an official decision from Medicare, you have to sign the ABN, agreeing to pay the cost if Medicare does not, and receive the care. You should be sure to have your provider bill Medicare for the service or item. Your provider is not required to submit the claim to Medicare unless you tell them, and Medicare will not provide coverage.

Appeals

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Medicare has rules about when beneficiaries should receive an ABN and how it should look. If they do not follow these rules, you may not be responsible for the cost of the care in question. If this is the case, you may have to file an appeal to prove this.

Check your Medicare Summary Notice (MSN) and when it shows that Medicare has denied payment for the service or item, you can then choose whether to file an appeal or not. Receiving an ABN does not prevent you from being able to file an appeal, as long as your provider billed Medicare for the service.

You could not be responsible for your denied charges if the ABN meets the following requirements:

  • Does not list services that are provided or is signed after the date the service was provided
  • Difficult to read or hard to understand
  • Given by the provider to every patient without a specific reason about why the claim may be denied (unless from a lab)
  • Given to you during an emergency
  • Given to you just prior to receiving the service

You may not need to pay for the service or item if you also meet the following requirements:

  • You did not receive an ABN from your provider before you were given the service.
  • An ABN was not provided when it should have been.
  • Your service or item is not specifically excluded from your Medicare coverage.
  • Your provider had reason to believe that your service would not be covered by Medicare.
  • Medicare has denied coverage for your service or item.

For more information, contact your provider any services and your coverage.

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Hannah Verret is a content developer at Medicare World in Memphis, TN. Hannah has been working in content creation throughout her entire adult career. When Hannah isn’t writing or organizing social media posts, she’s spending her time reading and loving on her many pets.

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