An Advance Beneficiary Notice of noncoverage (ABN) informs a person that Medicare may not pay for a specific service or item.
A healthcare provider generally sends the ABN, although a skilled nursing facility or hospital may send one when they believe that Medicare might not continue to cover a person’s care. A person enrolled in original Medicare may get the notice, but a person with a Medicare Advantage plan would not receive one.
This article discusses what an ABN is and the three options for responding to the notice. It also looks at the details of an ABN from a skilled nursing facility or a hospital and explains how to file an appeal, including a fast, or expedited, appeal.
When a doctor, supplier, or other healthcare provider believes that Medicare is unlikely to pay for a service, they send a person an ABN. The notice allows the individual to decide whether they want to get the service despite the unlikelihood of coverage, which may mean that they will need to accept responsibility for the payment.
The ABN includes:
- the specific service or item for which the provider does not expect payment from Medicare
- an estimate of the cost of the item or service
- the reasons why Medicare may not cover the cost
In addition, the ABN gives a person three response options. The provider asks the individual to select one of the options and then sign the form, which indicates that they have read and understood it.
It is important to note that an ABN is not an official denial of coverage but is merely the notification of the probability of noncoverage.
In addition, a person will not receive an ABN for any items that original Medicare does not cover, including:
- long-term care
- dental care, in most cases
- eye exams, if they are in relation to prescribing glasses
- cosmetic surgery
- hearing aids, including the fitting exams
- routine foot care
In response to the ABN, people have the following three options:
A person wants the service or item despite the likelihood that Medicare will not cover it. They ask the provider to submit the claim to Medicare. If Medicare does not pay for the service, the person must pay for it. The provider may ask for payment at that time.
However, as the provider submitted the claim, the individual may appeal to Medicare. After the appeal, if Medicare decides to pay for the service, the provider refunds the payment to the person.
An individual wants the service but asks the provider not to submit the claim to Medicare. The provider may ask for payment at that time. As the person did not ask the provider to submit the claim to Medicare, they cannot file an appeal.
A person does not want the service that Medicare may not cover, so they are not responsible for payment. The provider does not submit the claim to Medicare, and the individual cannot file an appeal.
Aside from an ABN from the provider of a service or item, an ABN may also come from a skilled nursing facility or hospital.
Skilled nursing facility ABN
A skilled nursing facility ABN lets a person know that Part A may not continue to pay for their care. If someone’s stay in a facility is not necessary or reasonable, Medicare considers it custodial, which is not covered.
If a person chooses to get the continued care that Medicare may not cover, they do not have to pay for it until the facility submits the claim, and Medicare denies payment. While Medicare is processing the claim, a person has to continue paying out-of-pocket costs, such as coinsurance.
Hospital-issued notice of noncoverage
A hospital-issued notice of noncoverage lets an individual know that Medicare may not cover all or part of their Part A inpatient care. The notice provides the reason why Medicare might not pay, and it specifies the amount that the person would have to pay should they choose to continue to receive the hospital services.
If a person disagrees with a Medicare coverage or payment decision, they may file an appeal. An appeal is an option if Medicare denies any of the following:
- a request for a service or item that a beneficiary would like
- a request for payment of a service or item that a beneficiary has already received
- a request to change the amount that a beneficiary must pay for a service or item
To appeal, a person may wish to ask their doctor or healthcare provider for any information that may support their case. The appeal process involves five levels, so if an individual disagrees with a decision, they may usually move on to the next level.
When Medicare makes a decision at each level, it sends a person a letter with instructions on how to proceed.
People have the right to an expedited appeal if they believe that the services they get will end before the likely completion of the appeal process. Such services may come from a:
- skilled nursing facility
- outpatient rehabilitation facility
- home health agency
A provider will give a person a written notice before their service ends. The notice includes instructions on how to ask for a fast appeal. In instances when an individual does not receive the notice, they may request it from the provider.
Medicare sometimes does not pay for a service or item that a person wants. Also, it occasionally does not pay for a service or item as frequently or for as long as an individual would prefer. If providers know that either of these two scenarios is likely, they send someone an ABN.
When this happens, the person may choose to accept responsibility for payment, but they may request that the provider file the claim with Medicare. If Medicare declines to cover the payment, the individual may appeal the decision.