(Medicare Claims Processing Manual)

A reduction occurs when there is a decrease in a component of care (i.e. frequency, duration, etc.).  The ABN is not issued every time an item or service is reduced.  But, if a reduction occurs and the beneficiary wants to receive care that is no longer considered medically reasonable and necessary, the ABN must be issued A termination is the discontinuation of certain items or services.  The ABN is only issued at termination if the beneficiary wants to continue receiving care that is no longer medically reasonable and necessary.    prior to delivery of this non-covered care.   50.5 - ABN Standards                                                                                (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21)  The ABN, Form CMS -R-131, is the OMB approved standard written notice.  Failure to use this notice as mandated could result in the  notice being invalidated and/or the notifier being held liable for the items or services in question.  The online replicable copies of the OMB approved ABN (CMS -R-131) and instructions for notice completion are available on the CMS website at:  http://www.cms.gov/Medicare/Medicare -General - Information/BNI/ABN.html  A. Language  Choice    The ABN is available in English and Spanish under a dedicated link on the web page given above.  Notifiers should choose the appropriate version of the ABN based on the language the beneficiary best understands.  Insertions must be in English when the Engl ish language ABN is used.  Similarly, when a Spanish language ABN is used, the notifier should make insertions on the notice in Spanish, if applicable.  In addition, verbal assistance in other languages may be provided to assist beneficiaries in understanding the document.  However, the printed document is limited to the OMB -approved English and Spanish versions.  Notifiers should document any types of translation assistance that are used in the Additional Information section of the notice.   B.  Effective Versions   ABNs are effective as of the OMB approval or expiration date given at the bottom of each notice.  The routine approval is for 3 -year use.  Notifiers are expected to exclusively use the current version of the  ABN.  CMS will allow a transition period for he althcare providers and suppliers to switch from using expiring notices to newly approved notices.   C. General Notice Preparation Requirements   Number of Copies  A minimum of two copies, including the original, should be made so the beneficiary and notifier each have one.  The notifier should retain the original whenever  possible.  Reproduction  Notifiers may reproduce the ABN by using self -carbonizing paper, photocopying, digitized technology, or another appropriate method.  All reproductions should conform to applicable requirements.  Length and Size of Page  The ABN form must not exceed one page in length; however, attachments are permitted for listing additional items and services.  If attachments are used, they should allow for clear matching of the items or services in question with the reason and cost esti mate information.  The ABN is designed as a letter - sized form.  If necessary, it may be expanded to a legal -sized  page.  Contrast of Paper and Print  A visually high -contrast combination of dark ink on a pale background should be used .  Do not use reversed print (i.e. white print on black paper), or block -shaded (highlighted)  text.  Font  Fonts as they appear in the ABN downloaded from the CMS web site should be used.  In cases where changes need to occur, notifiers should use alternative fonts that are easily readable, such as Arial, Arial Narrow, Times New Roman, and Courier.   Any other changes to the font, such as italics, embossing, bold, etc., should not be used since they can make the ABN more difficult to read.  The font size generally should be 12 point.  Titles should be 14 -16 point, but insertions in blanks of the ABN ca n be as small as 10 point if needed.  Information inserted by notifiers in the blank spaces on the ABN may be typed or legibly hand -written.  Customization  Notifiers are permitted to do some customization of ABNs, such as pre -printing information in certain blanks to promote efficiency and to ensure clarity for beneficiaries.  Notifiers may develop multiple versions of the ABN specialized to common treatment scenarios, using the required language and general formatting of the ABN.   Blanks (G) -(I) must be completed by the beneficiary when the ABN is issued and should not be pre -filled.  Lettering of the blanks (A- J) should be removed prior to issuance of an  ABN.  If pre -printed information is used to describe items/services and/or common reasons for non -coverage, the notifier must clearly indicate on the ABN which portions of the pre - printed information are applicable to the beneficiary  Healthcare providers or suppliers who pre-print a menu of items or services may wish to list a cost estimate alongside each item or service.   Modification  The ABN may not be modified except as specifically allowed by these instructions.  Notifiers must exercise caution before adding any customizations beyond these guidelines, since changing ABNs too much could result in invalid notice and healthcare provider or supplier liability for non -covered charges.  Validity judgments are generally made by Medicare contractors, usually when reviewing ABN -related claims; however, any complaints received may be investigated by contractors and /or CMS central or regional offices.   50.6 - Completing the ABN                                                                        (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21) Step-by-step instructions for notice completion are posted along with the notice on the CMS website and can be downloaded via this link:  http://www.cms.gov/Medicare/Medicare -General -Information/BNI/ABN.html   A. Other Considerations During ABN Completion   1.  Beneficiary Changes His/her Mind   If after completing and signing the ABN, a beneficiary changes his/her mind, the notifier should  present the previously completed ABN to the beneficiary and request that the beneficiary annotate the original ABN.  The annotation must include a clear indic ation of his/her new option selection along with the beneficiary's signature and date of annotation.  In situations where the notifier is unable to present the ABN to the beneficiary in person, the notifier may annotate the form to reflect the beneficiary's new choice and immediately forward a copy of the annotated notice to the beneficiary to sign, date, and return.   In both situations, a copy of the annotated ABN should be provided to the beneficiary as soon as possible.  If a related claim has been filed, it should be revised or cancelled if necessary to reflect the beneficiarys new choice.   2.  Beneficiary Refuses to Complete or Sign the Notice   If the beneficiary refuses to choose an option and/or refuses to sign the ABN when required, the notifier should annotate the original copy of the ABN indicating the refusal to sign or choose an option and may list witness(es) to the refusal on the notice although this is not required.  If a beneficiary refuses to sign a properly delivered ABN, the notifier should consider not furnishing the item/service, unless the consequences (health and safety of the patient, or civil liability in case of harm) are such  that this is not an option.  In any case, the notifier should provide a copy of the annotated ABN to the beneficiary, and keep the original version of the annotated notice in the patients file.   50.7 - ABN Retention                                                                                 (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21) The notifier should retain the ABN delivered to the beneficiary on file should there be any question regarding whether the beneficiary had knowledge of the potential financial liability.    In certain situations, such as delivery by fax, the notifier may not have access to the original document upon signing.  Retention of a copy of the signed document would be acceptable in specific cases such as this.   In a case where the notifier that gives an ABN is not the entity that ultimately bills Medicare for the item or service (e.g. when a physician issues an ABN, draws a test specimen, and sends it to a laboratory for testing), the notifier should give a copy of the signed ABN to the billing entity.    In general, it is 5 years from discharge/completion of delivery of care when there are no other applicable requirements under State law.  Electronic retention of the signed paper document is acceptable.  Notifiers may scan the signed paper or wet version  of the ABN for electronic medical record retention and if desired, give the paper copy to the beneficiary.     50.8 - Effective ABN Delivery                                                                    (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21)  ABN delivery is considered to be effective when the ABN is:   1. Delivered by a suitable notifier to a capable recipient and comprehended by that recipient.   2. Provided using the correct OMB approved notice with all required blanks  completed.  Failure to use the correct notice may lead to the notifier being found liable since the burden of proof is on the notifier to show that knowledge was conveyed to the beneficiary according to CMS instructions.  3. Delivered to the beneficiary in person if  possible.   4. Provided far enough in advance of delivering potentially non- covered items or services to allow sufficient time for the beneficiary to consider all available options.   5. Explained in its entirety, and all of the beneficiarys related questions are answered timely, accurately, and completely to the best of the notifiers  ability.   The notifier should direct the beneficiary to call 1- 800-MEDICARE if the beneficiary has questions s/he cannot answer.  If a Medicare contractor finds that the notifier refused to answer a beneficiarys inquiries or direct them to 1- 800-MEDICARE, the notice delivery will be considered defective, and the notifier will be held financially liable for non- covered care.   6. Signed by the beneficiary.  A. Period of Effectiveness/Repetitive or Continuous Non -covered Care   An ABN remains effective after valid delivery so long as there has been no change in:    Care from what is described on the original ABN;   The beneficiarys health status which would require a change in the subsequent treatment for the non -covered condition; and/or   The Medicare coverage guidelines for the items or services in question (i.e., updates or changes to the policy of an item or service).   NOTE:   If any of the above changes during the course of treatment, a new ABN must be issued.  For items or services that are repetitive or continuous in nature, notifiers may issue another ABN to a beneficiary after one year for subsequent treatment for the non-covered condition.  However, this is not required unless any of the conditions described above apply to the given situation.   Notifiers may give a beneficiary a single ABN describing an extended or repetitive course of non -covered treatment provided that the ABN lists all items and services that the notifier believes Medicare will not cover.  If applicable, the ABN must also spec ify the duration of the period of treatment.  If during the course of treatment additional non-covered items or services are needed, the notifier must give the beneficiary another ABN.   If a beneficiary is receiving repetitive non -covered care, but the healthcare provider or supplier failed to issue an ABN before the first or the first few episodes of care were provided, the ABN may be issued at any time during the course of treatment.  H owever, if the ABN is issued after repetitive treatment has been initiated, the ABN cannot be retroactively dated or used to shift liability to the beneficiary for care that had been provided before ABN issuance.  In cases such as this, care that was provi ded before ABN delivery would be the financial responsibility of the healthcare provider or supplier.  B. Incomplete ABNs   Allegations of improper or incomplete notices will be investigated by Medicare contractors.  If the notifier is found to have given improper or incomplete notice, the applicable Medicare contractor will not hold the beneficiary liable in the individual case.   C. Electronic Issuance of the ABN   Electronic issuance of ABNs is not prohibited.  If a healthcare provider or supplier elects to issue an ABN that is viewed on an electronic screen before signing, the beneficiary has the option of requesting paper issuance over electronic if that is what s /he prefers.  Also, regardless of whether a paper or electronic version is issued and regardless of whether the signature is digitally captured or manually penned, the beneficiary should be given a paper copy of the signed ABN to keep for his/her own recor ds.    50.8.1- Options for Delivery Other than  In-Person  (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21)