One of the most challenging aspects of handling an advance beneficiary notice (ABN form) is identifying when you MUST present it to your patient and when it’s considered “voluntary.” The line between these two seemingly similar situations could be what separates a paid claim from a denial.

Get the facts on when an ABN form is voluntary and when it’s mandatory with a few simple tips below.

8 Times an ABN Form Is Mandatory

The advance beneficiary notice is mandatory for non-covered Medicare services in the following eight situations. Keep in mind that these scenarios apply to patients with traditional Medicare coverage — Medicare Advantage is a completely different situation with its own set of rules.

1. Not Reasonable and Necessary. In these situations, Medicare may have already told you in some form or fashion that the service you plan to perform isn’t reasonable or necessary, and you should have the patient sign an ABN to ensure that they know how much they’ll be expected to pay for the service.
2. Violates Unsolicited Phone Contact Prohibition. If the item or service you provided is in violation of the prohibition on unsolicited telephone contacts, you must ask the patient to sign an ABN.
3. No Supplier Number. In some cases, the item or service is for medical equipment and supplies for which the supplier number is not provided. In these instances, an ABN is mandatory.
4. Supplies Denied in Advance. Sometimes, you already know that the item or service is for medical equipment and /or supplies that Medicare has denied in advance. Here you’ll want to get an ABN signed by the patient.
5. Custodial Care. This refers to non-medical care that non-licensed caregivers can provide, and it should trigger an ABN.
6. Hospice Care for Non-Terminal Patient. Medicare only covers hospice care for patients who are terminally ill. If a patient wants hospice services and is not deemed terminally ill, you should have them sign an ABN form.
7. Non-Contract Supplier. If the item or service is furnished by a noncontract supplier and the item is included in the DMEPOS Competitive Bidding Program (CBP) for a Competitive Bidding Area, the patient should sign an ABN form.
8. Exceeded Preventive Frequency Limitations. Some preventive services are subject to frequency limitations, but if your patient requests one of those services despite having already met the frequency limit, ask them to sign an ABN.

8 Times the ABN Form is Voluntary

In the situations below, the patient is not required to sign an ABN, but you can ask them to complete one anyway to protect yourself in the event of a denial.

1. Services for Which There’s No Legal Obligation to Pay. If you’re not sure whether or not a service will be covered by Medicare, you might consider asking the patient to sign an ABN.
2. Services Paid for by a Government Entity Other Than Medicare. If the patient’s services have already been reimbursed by a government insurer besides Medicare, the ABN is voluntary.
3. Services Required as a Result of War. Although this situation is quite uncommon in today’s environment, it’s an important point to be aware of.
4. Personal Comfort Items. Patients may need personal comfort items to deal with their medical conditions, but those items may not be payable by Medicare. In these situations, it may be helpful to have patients sign an ABN.
5. Routine Physicals and Most Screening Tests. These services are typically not covered by Medicare, but it can sometimes be a good idea to have patients sign an ABN in these situations.
6. Routine Eye Care. Although some services may be covered on the same visit when the patient gets a routine eye exam, routine eye care won’t be payable, so it can help to have these patients sign an ABN.
7. Dental Care. If you perform dental services, which aren’t covered by traditional Medicare, an ABN may be a good idea.
8. Routine Foot Care. Some patients may not realize routine foot care isn’t payable by Medicare, so an ABN can be helpful to ensure patients are aware of their obligation.

You can get much more information about when to use an ABN form — simply join the latest online training event from Owen Dahl, FACHE, CHBC, LSSMBB. During his recent session, Mandatory vs. Voluntary: Stamp Out Medicare ABN Form Confusion, you’ll gain exclusive tips that will help you utilize the ABN every time you need it. Register today!

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