Your doctors and other health care providers must give you an advance beneficiary notice of noncoverage (ABN) if they believe that Medicare won’t pay for items, procedures or other services related to your medical care. This notice, given to you before you receive the care, lists what might not be covered, the reason why Medicare may not pay — and the estimated cost.
Because it comes from your provider, this notice, actually a form, isn’t an official denial from Medicare. But it’s a warning that if you decide to go ahead with a procedure, you’ll probably have to pay the full cost yourself. You must check one of three boxes on the form choosing if you:
This notice applies to recipients of original Medicare, which includes Medicare Part A and Part B, but not for private Medicare Advantage plans.
You’ll likely get one of these forms in person while you’re visiting your health care provider. But Medicare allows doctors, hospitals or medical equipment suppliers to deliver a copy of the form to a secure fax machine, send the form in the mail, talk to you on the telephone or use email to send you the form. They must give you the form far enough in advance so you have time to consider your options, although the government has not set a specified time period.
They must be able to verify that contact was made directly with you because federal health privacy laws restrict the sharing of certain health information and records.
Don’t ignore the form when you receive it. You’ll need to choose one of the options and sign the form. If you refuse to sign, you might not receive the services you’re expecting.
If your secondary insurance is a Medigap policy, it generally won’t pay for services that Medicare denies.
If the claim is submitted to Medicare, you’ll receive a Medicare summary notice, which is similar to an explanation of benefits for other health coverage, letting you know if the claim was approved or denied. This form includes instructions for appealing a claim denial.
Doctors and other health care providers, ambulance companies, equipment suppliers, home health agencies, hospice services and independent laboratories must provide the notice in situations when they expect Medicare payment will be denied.
You may receive an ABN before receiving a service, which could include:
Hospitals and skilled nursing facilities have a different advance beneficiary notice of noncoverage for services that Medicare Part A is unlikely to cover, such as services considered not medically necessary.
If a provider knows that a service is unlikely to be covered but doesn’t give you an ABN beforehand, you may not be responsible for the cost of care. But that’s true only if Medicare denies the claim and you submit an appeal based on that assertion.
Relying on this possibility could be risky. So it’s important to check with your provider about all prescribed treatments, recommended procedures or desired services before you schedule them.
Yet providers aren’t required to give you an ABN for care and equipment that Medicare never covers, such as cosmetic surgery, hearing aids and routine eye care for most people.
Published November 22, 2022
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