CMS Issues ABN Update

CMS Issues ABN Update

Are you using the most current ABN?

A new Fee-for-Service Advanced Beneficiary Notification of Non-coverage (ABN) form is now effective, with an expiration date of June 30, 2023. The use of the old ABN (version 03/2020) will be considered invalid after Aug. 31, 2020.

Update: Due to COVID-19 concerns, CMS has expanded the deadline for use of the renewed ABN, Form CMS-R-131 (exp. 6/30/2023).  At this time, the renewed ABN will be mandatory for use on Jan. 1, 2021.  The renewed form may be implemented prior to the mandatory deadline. 

What’s Changed in the ABN?

Guidelines for dual eligible beneficiaries (patients with both Medicare and Medicaid coverage) have been added to the ABN form instructions. The changes were necessary to comply with billing prohibitions for patients in a Qualified Medicare Beneficiary (QMB) program. The QMB program helps pay Part A, Part B, or both program premiums, deductibles, coinsurance, and copayments.

Special Instructions Apply

Patients in a QMB program cannot be charged for Medicare cost sharing for covered Parts A and B services, nor can they elect to pay Medicare cost sharing. As such, special instructions apply when a provider issues an ABN to a dual eligible beneficiary:

Dually eligible beneficiaries must be instructed to check Option Box 1 on the ABN in order for a claim to be submitted for Medicare adjudication.

Strike through Option Box 1 as provided below:

□ OPTION 1. I want the D. [service or supply] 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 the directions on the MSN.

ABN 6/30/2023

If Medicare denies a claim where an ABN was needed in order to transfer financial liability to the patient, the claim may be crossed over to Medicaid or submitted by the provider for adjudication based on state Medicaid coverage and payment policy.

Once the claim is adjudicated by both Medicare and Medicaid, providers may only charge the patient in the following circumstances:

  • If the patient has QMB coverage without full Medicaid coverage, the ABN could allow the provider to shift financial liability to the patient per Medicare policy.
  • If the patient has full Medicaid coverage and Medicaid denies the claim (or will not pay because the provider does not participate in Medicaid), the ABN could allow the provider to shift financial liability to the patient per Medicare policy, subject to any state laws that limit beneficiary liability.

These instructions should only be used when the ABN is used to transfer potential financial liability to the beneficiary and not in voluntary instances.

Find Out More About ABNs

More information on dual eligible beneficiaries may be found on the CMS website. Guidelines for issuing the ABN can be found beginning in Section 50 in the Medicare Claims Processing Manual, Pub. 100-4, Chapter 30. The revised ABN form may be downloaded from the CMS website.

Renee Dustman
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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

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