MLN BookletMedicare Advance Written Notices of Non-coverage
MLN006266 June 2022Page 2 of 12
Table of Contents
What’s Changed? ................................................................................................................................ 3
Types of Advance Written Notices of Non-coverage ....................................................................... 4
Issuing an Advance Written Notice of Non-coverage ...................................................................... 5
Prohibitions & Frequency Limits ....................................................................................................... 8
Repetitive or Continuous Non-covered Care .................................................................................... 9
Completing an Advance Written Notice of Non-coverage ............................................................... 9
Collecting Patient Payment .............................................................................................................. 10
Financial Liability ...............................................................................................................................11
ABN Claim Reporting Modiers ........................................................................................................11
When Not to Use an Advance Written Notice of Non-coverage .................................................... 12
Resources .......................................................................................................................................... 12
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An advance written notice of non-coverage helps Medicare Fee-for-Service (FFS) patients choose
items and services Medicare usually covers but may not pay because they’re not medically necessary
or custodial in nature. You communicate these nancial liabilities and appeal rights and protections
through notices you give your patients. If you don’t provide your patients with the required written
notices, we may hold you nancially liable if we deny payment. This booklet explains the advance
written notice types, uses, and timing.
“You” refers to the health care provider or supplier.
Types of Advance Written Notices of Non-coverage
CMS uses these notices:
●
Advance Beneciary Notice of Non-coverage (ABN)
(CMS-R-131) — All health care providers and suppliers must
issue an ABN when they expect a payment denial that transfers
nancial liability to the patient. This includes:
●
Part B (outpatient) items and services provided in
independent labs, skilled nursing facilities (SNFs), and home
health agencies (HHAs)
●
Part A (inpatient) items and services provided by hospice
providers, HHAs, and religious non-medical health care
institutions (RNHCIs)
Notiers are entities who
issue ABNs. These entities
can include physicians,
practitioners, health care
providers (including labs),
suppliers, and utilization
review committees for the
care provider.
●
Skilled Nursing Facility Advance Beneciary Notice of Non-coverage (SNF ABN) (CMS-10055) —
SNFs must issue a SNF ABN to transfer nancial liability to the patient before providing a Part A
item or service that we usually pay, but may not because it’s medically unnecessary or custodial care.
●
Hospital-Issued Notices of Non-coverage (HINN) — Hospitals must issue a HINN before or at
admission, or during an inpatient stay if they determine the patient’s care isn’t covered because it’s:
●
Medically unnecessary
●
Not delivered in the most appropriate setting
●
Custodial in nature
Sections 220 and 240 of Medicare Claims Processing Manual, Chapter 30 has more
HINN information.
Hospitals issue 4 dierent HINNs:
1. HINN 1 — Pre-admission/Admission HINN: Use before an entirely non-covered stay
2. HINN 10 — Notice of Hospital Requested Review (HRR): Use for FFS and Medicare
Advantage Program (Part C) patients when requesting Quality Improvement Organization
(QIO) discharge decision review without provider agreement
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3. HINN 11 — Non-covered Service(s) During Covered Stay: Use for non-covered items and
services during an otherwise covered stay
4. HINN 12 — Non-covered Continued Stay: Use with the Hospital Discharge Appeal Notices to
inform patients of their non-covered continued stay potential liability
Beneciary Notices Initiative (BNI) webpage has copies of the HINNs.
Medicare Outpatient Observation Notice (MOON) (CMS-10611) — The MOON informs patients
when they’re an outpatient getting observation services and aren’t a hospital or CAH inpatient.
Section 400 of Medicare Claims Processing Manual, Chapter 30 has more information.
Issuing an Advance Written Notice of Non-coverage
When to Issue an Advance Written Notice of Non-coverage
Advance written notice of non-coverage recipients include patients who have Original Medicare FFS
coverage. To transfer nancial liability to the patient, you must issue an advance written notice
of non-coverage:
●
When a Medicare item or service isn’t reasonable or necessary under Program standards,
including care that’s:
●
Not indicated for the diagnosis, treatment of illness, injury, or to improve the functioning of a
malformed body member
●
Experimental and investigational or considered research only
●
More than the number of services allowed in a specic period for that diagnosis
●
When providing custodial care
●
When outpatient therapy services exceed therapy threshold amounts
●
Before caring for a patient who isn’t terminally ill (hospice providers)
●
Specic items or services billed separately from the hospice per diem payment (for example,
physician services) that aren’t reasonable or necessary
●
Level of hospice care isn’t reasonable or medically necessary
●
Before caring for a patient who isn’t conned to the home or doesn’t need intermittent SNF care
(HHA providers)
●
Before providing a preventive service we usually cover but won’t cover in specic situations when
services exceed frequency limits
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●
Before providing a Medicare item or service we cover (Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies [DMEPOS] suppliers) because:
●
Provider accepted prohibited unsolicited phone contacts
●
Supplier hasn’t met supplier number requirements
●
Non-contract supplier provides an item listed in a competitive bidding area
●
Patient wants the item or service before the advance coverage determination
Non-Contract DMEPOS Suppliers
An ABN is valid if a patient understands what the notice means. An exception applies when
patients have no nancial liability to a non-contract supplier of an item from the Competitive
Bidding Program unless they sign an ABN indicating Medicare won’t pay for the item because
they got it from a non-contracted supplier and they agree to accept nancial liability.
Services must meet specic medical necessity requirements in the statute, regulations, guidance, and
criteria dened by National Coverage Determinations (NCDs) and Local Coverage Determinations
(LCDs) (if any exist for the service reported). Every service you bill must indicate the specic sign,
symptom, or patient complaint that makes the service reasonable and necessary.
NCDs or LCDs may limit coverage. NCDs limit specic Medicare service, procedure, or technology
coverage on a national basis. The HHS Secretary determines reasonable and necessary NCDs.
Medicare Administrative Contractors (MACs) may develop an LCD to further dene an NCD or if
there’s no specic NCD. This coverage decision gives guidance to the public and medical community
within a specied geographic area. In most cases, this information’s availability indicates you knew
, or
should’ve known, we would deny the item or service as medically unnecessary.
Issuing an Advance Written Notice of Non-coverage as a Courtesy
We don’t require you to notify the patient before you provide an item or service we never cover
or isn’t a Medicare benet. However, as a courtesy, you may issue a voluntary notice to alert the
patient about their nancial liability. Issuing the notice voluntarily doesn’t aect nancial liability, and
the patient isn’t required to check an option box or sign and date the notice. Items & Services Not
Covered Under Medicare booklet has more information about non-covered services.
Events Prompting an Advance Written Notice of Non-coverage
These 3 triggering events may prompt an advance written notice of non-coverage:
1. Initiations
2. Reductions
3. Terminations
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Initiations
Initiations happen at the beginning of a new patient encounter, start of a plan of care (POC), or when
treatment begins. If you believe at initiation we won’t cover certain items or services because they’re
not reasonable and necessary, you must issue the notice before the patient gets the non-covered
care to transfer nancial liability.
Reductions
Reductions happen when a component of care decreases (for example, frequency or service
duration). Don’t issue the notice every time there’s a care reduction. If a reduction happens and the
patient wants to continue getting care no longer considered medically reasonable or necessary, you
must issue the notice before the patient gets the non-covered care to transfer nancial liability.
Terminations
Terminations stop all or certain items or services. If you terminate services and the patient wants to
continue getting care no longer considered medically reasonable or necessary, you must issue the
notice before the patient gets the non-covered care to transfer nancial liability.
Issuing an Advance Written Notice of Non-coverage When Multiple
Entities Provide Care
When multiple entities provide care, we don’t require separate advance written notices of non-coverage.
Any notier involved in delivering care can issue the notice when:
●
There’s separate ordering and delivering providers (for example, a provider orders a lab test and
an independent lab delivers it)
●
A provider delivers the technical component, and another delivers the same service’s professional
component (for example, a radiology test from an independent diagnostic testing facility, and
another provider interprets the results)
●
The entity that gets the signature on the notice isn’t the same entity billing the service (for
example, a lab refers a specimen to another lab and the second lab bills us)
In these situations, you may enter more than 1 notier in the form’s header
, space A. Notier, if the
patient can clearly identify who to contact with billing questions.
We hold the billing notier responsible for issuing the notice.
MLN BookletMedicare Advance Written Notices of Non-coverage
MLN006266 June 2022Page 8 of 12
Prohibitions & Frequency Limits
Routine Notice Prohibition
There’s no reason to issue an advance written notice of non-coverage on a routine basis, except for:
●
Experimental items and services
●
Items and services with frequency coverage limitations
●
Medical equipment and supplies denied because the supplier had no supplier number, or the
supplier made an unsolicited phone contact
●
Medically unnecessary services always denied
Other Prohibitions
You can’t issue an advance written notice of non-coverage to:
●
Shift liability and bill the patient for services denied due to a Medically Unlikely Edit (MUE)
●
Compel or coerce patients in a medical emergency or under great duress
●
Using an advance written notice of non-coverage in the emergency room or during ambulance
transports may be appropriate in some cases (for example, a patient who’s medically stable
and not under duress)
●
Charge a patient for part of a service when we fully pay through a bundled payment
●
Transfer liability to the patient when we would otherwise pay for items and services
Frequency Limits
Some Medicare-covered services have frequency limits. We pay only a certain amount of a specic
item or service in each diagnosis period. If you believe an item or service may exceed frequency
limits, issue the notice before providing it to the patient.
If you don’t know the number of times the patient got a service within a specic period, get this information
from them or other providers involved in their care. Find your MAC’s website or check for eligibility to
determine if a patient met the frequency limits from another provider during the calendar year.
Medicare Preventive Services educational tool has more information on Medicare-covered services
that have frequency limits.
Extended Treatment
You may issue a single notice to cover extended treatment if it lists all items and services and the
duration of treatment when you believe we won’t pay. If the patient gets an item or service during the
treatment that you didn’t list on the notice and we may not cover it, you must issue a separate notice.
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Repetitive or Continuous Non-covered Care
An ABN remains eective after delivery if there’s no change in:
●
Care described on the original ABN
●
Patient’s health status
●
Medicare coverage guidelines for the items or services in question (for example, updates or
changes to the policy of an item or service)
Note: If any bullets above change during treatment, issue a new ABN.
For repetitive or continuous items or services, you may issue the patient another ABN after 1 year for
subsequent treatment of the non-covered condition. This isn’t required unless any conditions above
apply to the situation.
You may give a patient a single ABN describing an extended or repetitive non-covered treatment
course if the ABN lists all items and services you believe we won’t cover. If applicable, the ABN must
also specify the treatment duration.
If a patient is getting repetitive non-covered care but you failed to issue an ABN before providing the
rst episodes of care, you may issue the ABN at any time during treatment. However, if you issued
the ABN after initiating repetitive treatment, the ABN can’t be retroactively dated or used to shift
liability to the patient for care provided before you issued the ABN. In these cases, care provided
before ABN delivery is the health care provider’s or supplier’s nancial responsibility.
Completing an Advance Written Notice of Non-coverage
An advance written notice of non-coverage should be:
●
Issued (preferably in person) and understood by the patient or their representative.
●
Completed on the approved, standardized notice format (when applicable), with all required blanks
completed. It can’t exceed 1 page. You may include attachments listing additional items and
services. If you use attachment sheets, they must clearly match the items or services in question
with the reason a denial is expected and cost estimate information. The patient should be able
to read it. We permit limited advance written notice of non-coverage customization, such as pre-
printing information in certain blanks.
●
Issued far enough in advance for potentially non-covered items or services so the patient can
consider available options.
●
Explained in its entirety, with you answering all notice-related questions.
●
Signed and dated by the patient or their representative after they select an option. If you issue
the notice electronically, oer the patient a paper copy and keep a copy for your records (whether
signed on paper or electronically). If you maintain electronic medical records, you may scan the
signed hard copy.
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●
Kept for 5 years from the date-of-care delivery when no other requirements under state law apply.
We require you to keep all notice records, including when the patient declined care, refused an
option, or refused to sign the notice.
If you can’t issue the notice in person, you may issue it via direct phone, email, mail, or secure fax
machine (according to HIPAA policy). The patient shouldn’t dispute the contact. You should document
the contact in the patient’s records and keep the unsigned notice copy on le while you wait for the
signed notice.
You must follow phone contacts immediately with a hand-delivered, mailed, emailed, or faxed
advance written notice of non-coverage. The patient or the patient’s representative must sign and
keep the notice and send you a signed copy for their medical record. If the patient fails to return a
signed copy, document the initial contact and subsequent attempts to get a patient’s signature.
Find detailed instructions on how to complete an ABN in the Advance Beneciary Notice of
Non-coverage Tutorial.
When Patients Change Their Minds
If a patient changes their mind after completing and signing the notice, ask them to add explanatory
notes to their notice. They must sign and date the notes and clearly indicate their new selection. If you
can’t provide the notice in person, you may add explanatory notes to the form that show the patient’s
new selection and immediately forward a copy to the patient to sign, date, and return. Y
ou must
provide them a copy of the revised notice as soon as possible.
Patient Refusal to Choose Option or Sign Advance Written Notice of
Non-coverage
If the patient or their representative refuses to choose an option or sign the notice, you should add
notes to the original copy indicating their refusal. You may list any refusal witnesses even though a
witness isn’t required. If a patient refuses to sign a properly issued notice, consider not providing the
item or service unless the consequences prevent it (health and safety of the patient or civil liability in
case of harm).
Collecting Patient Payment
When we require an advance written notice of non-coverage, if you properly notify patients that we
may not cover the item or service and they sign the notice, you may seek payment from them. If we
pay all or part of the item or service claim the patient paid, you must refund them the proper amount
in a timely manner. We consider refunds timely within 30 days after you get the Remittance Advice or
within 15 days after an appeal determination if you or the patient le an appeal.
Note:
We don’t allow SNFs to collect Part A services money until the MAC makes an ocial claim
payment decision. Distinct dually eligible billing limitations apply, including Qualied Medicare
Beneciaries (QMBs).
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Financial Liability
If you don’t issue a required notice or your MAC nds the notice invalid and you knew, or should’ve
known, we won’t pay for a usually covered item or service, we may hold you nancially liable. You
can’t collect payment from the patient. If you previously collected the patient’s payment, refund the
proper amount in a timely manner.
ABN Claim Reporting Modiers
Using Modiers for ABN Claim Reporting
Modier When to Use Modier
–GA
Waiver of Liability Statement
Issued as Required by Payer
Policy, Individual Case
Report when you issue a mandatory ABN for a service as
required and keep it on le. You don’t need to submit a copy
of the ABN, but you must make it available on request. Use
the –GA modier when both covered and non-covered services
appear on an ABN-related claim.
–GX
Notice of Liability Issued,
Voluntary Under Payer Policy
Report when you issue a voluntary ABN for a service we never
cover because it’s statutorily excluded or isn’t a Medicare
benet. Use this modier combined with modier –GY.
–GY
Notice of Liability Not Issued,
Not Required Under Payer
Policy
Report Medicare statutorily excludes the item or service, or
the item or service doesn’t meet the denition of a Medicare
benet. Use this modier combined with modier –GX.
–GZ
Expect Item or Service
Denied as Not Reasonable
and Necessary
Report when you expect we’ll deny payment of the item or
service because it’s medically unnecessary and you didn’t
issue an ABN.
–GK
Reasonable and Necessary
Item/Service Associated
with GA or GZ Modier
Report when upgrading a piece of equipment. If you have an
ABN, bill with –GA. If you don’t have an ABN, bill with –GZ.
–GL
Medically Unnecessary
Upgrade Provided Instead
of Non-Upgraded Item, No
Charge, No ABN
Report when you provide an upgraded item, but don’t charge
us or the patient for the non-upgraded item, and you didn’t
issue an ABN.
Section 60.4.2 of Medicare Claims Processing Manual, Chapter 1 has more ABN modier information.
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When Not to Use an Advance Written Notice of Non-coverage
Don’t use an advance written notice of non-coverage for items and services you provide under Medicare
Advantage Program (Part C) or the Medicare Drug Plans (Part D).
You don’t need to notify the patient before you provide items or services that aren’t a benet or
never covered.
Section 20.2.1 of Medicare Claims Processing Manual, Chapter 30 has a list of Medicare non-covered
items and services.
Resources
●
Email Your ABN Questions
●
Medicare Claims Processing Manual, Chapter 30
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