Master Core Curriculum

1. Master Core Curriculum Part B Intermediate Module 2 Advanced Beneficiary Notice (ABN)

2. Learning Outcomes At the end of this module, you will be able to: • identify the applicable form for use inpatient liability and service exclusion situations • identify beneficiary liability situations where the ABN/ NEMB is required • complete and administer the ABN/ NEMB correctly • submit a correctly coded claim in ABN/ NEMB situations

3. Advance Beneficiary Notice (ABN) • Written notification to inform patients Medicare will likely deny their service • For use only with Medicare beneficiaries • Allows beneficiary to make informed decisions regarding whether to receive items or services for which they may have to pay out of pocket

4. Approved Standard ABN Forms • ABN-G and ABN-L • Form numbers CMS-R-131-G and CMS-R-131-L • Available in English and Spanish versions • May be obtained online at: http://www.cms.hhs.gov/Medicare/bni/ • Effective January 1, 2003, providers and suppliers must use approved ABN forms • Must be prepared with original and at least one beneficiary copy

5. User-Customizable Sections • ABN-G • Header • “Items or Services” box • “Because” box • ABN-L • Header • Reasons • Box containing three columns for lab tests • Designed as letter-size form, but may be expanded to legal-size • May only be one page in length

6. Situations in which an ABN is Required • Whether to issue an ABN depends on provider’s expectation of Medicare payment or denial • If provider expects Medicare denial based on any of the following, an ABN should be issued: • Medical Necessity • Frequency-limited Items and Services • Experimental Items and Services

7. Completion of the ABN • Requirements: • Must use approved Form CMS R-131 • Complete header section with patient name and HICN • Identify specific item or service • Identify specific reason for expected Medicare denial • Estimated cost may be provided • Patient must personally select Option 1 or Option 2 • Beneficiary signature and date

8. Routine Notice Prohibition • Routine use of ABNs is ineffective and prohibited for the following circumstances: • Generic ABN • Not specific to service or reason for denial • Blanket ABN • “One size fits all” • Signed Blank ABN

9. Delivery of the ABN • Must be delivered prior to service rendered • Copy must be provided to beneficiary • ABNs should never be delivered to patients in emergency situations.

10. Modifiers for Services not Reasonable & Necessary • GA Modifier • Expect Medicare will deny item or service as not reasonable and necessary and have on file an ABN signed by the beneficiary • GZ Modifier • Expect Medicare will deny item or service as not reasonable and necessary and do not have on filean ABN signed by the beneficiary

11. Notice of Exclusions from Medicare Benefits (NEMB) • Written notification to inform patient of services that Medicare never covers • Used for statutorily non-covered services for which it is not appropriate to use an ABN • Allows patients to make informed consumer decisions about receiving items or services for which they must pay out of pocket • Use of the NEMB is voluntary • Providers are encouraged to discuss non-covered services with patient regardless of whether NEMB is used.

12. Approved Standard NEMB Forms •  NEMB Form • Form number CMS-20007 • Available in English and Spanish versions • May be obtained online at: http://www.cms.hhs.gov/medicare/bni/ • Providers may also use notices of their own design rather than NEMB form. • Other professional associations, with the approval of CMS, have developed service-specific NEMB-type notices that providers may use.

13. Completion of the NEMB • If NEMB form is used, the following sections should be completed: •  Header • Customizable • May include provider’s identifying information • Explanation Box • Description of items or services about which notice is given • Check-off Boxes • Identifies specific Medicare exclusions • Footer • Customizable • May include patient name, signature, and date

14. Modifier for Non-covered Items or Services • GY Modifier • Defined as “Item or service statutorilyexcluded or does not meet the definition of any Medicare benefit” • Use this modifier to indicate service is statutory excluded or non-covered • There is no requirement to file claim unless patient requests claim to be submitted • NEMB’s may be used for these services

15. Modifier for Non-covered Items or Services • Examples of when to use GY modifier • Personal comfort items, cosmetic surgery, etc. • Beneficiary is liable for all charges • Article regarding GY modifier available at following Website: www.cms.hhs.gov/medicare/bni/modchtgy.pdf

16. Chapter Review Slide • Review question….Under what circumstances should an ABN be administered? • Review question….Under what circumstances should an NEMB be administered?

17. Chapter References/ Citations • CMS Manual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 30, Sections 40-50, Form CMS-R-131 Advance Beneficiary Notice (ABN) • Program Memorandum, Transmittal B-01-58, Change Request 1820, Coding for Non-covered Services and Services not Reasonable and Necessary

18. Chapter References/ Citations • CMS Manual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 30, Sections 90, Form CMS-20007 - Notices of Exclusions From Medicare Benefits (NEMBs) • Program Memorandum, Transmittal AB-02-168, Change Request 2415, November 22, 2002, Advance Beneficiary Notice and DMEPOS Refund Requirements –Corrections to PM AB-02-114