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Beneficiary Notices Form

Music hello and welcome to our video regarding completing the ABN script completing an ABN is simple for your office we are going to break it down for you and make sure to pay close attention to the information given and what is required for a valid ABN there are ten blanks for completion in the ABN and they're labeled letter A through letter J your entries in these blanks may be typed or handwritten and they should be large enough to allow ease in reading first let's talk about the header information blanks a through C these blanks must be completed by the notifier prior to delivering the ABN the notifier is the entity that is issuing the ABN as the notifier you must place your name address and telephone number in blank a next we have blank B the patient's name you must indicate the patient's name exactly how it appears on there red white and blue Medicare card next we have blank C identification number the use of this field is optional notifiers may enter an identification number for the beneficiary do not use the beneficiary's Medicare number or their social security number on this notice next we are going to talk about the body of the ABN first we have blank D you can use these descriptors in the header of blank D item service laboratory tests test procedure care or equipment here in blank D is where you will list the specific items or services believed to be non covered on our example here we have a screening mammography listed in blank e you must explain in simple language the reason believed that the item or service could be reduced or denied on our example the beneficiary requested that a screening mammography be performed before she was eligible for the test other examples of acceptable reasons could be Medicare does not pay for this test for your condition or Medicare does not pay for experimental or research use tests in blank F an estimated cost must be indicated an estimated cost is expected to be within $100 or 25% whichever is greater for example if a service costs $500 the estimated costs that could be indicated in blank F must be a dollar amount greater than or equal to 375 or an amount between 400 and 600 dollars the amount can be no greater than $700 in our example we have indicated that the estimated cost of the screening mammography will be 350 dollars here we have another blank D use these descriptors item service laboratory tests test procedure care or equipment here in the G options area we have another blank D again use these descriptors item service laboratory test test procedure care or equipment now let's talk about the three options the beneficiary could select first we have option 1 this option allows the beneficiary to receive the items or services that are specified in blank D if the beneficiary chooses this option you are required to submit a claim to Medicare this will result in a payment decision that could be appealed a beneficiary should also choose this option if they need to obtain an official Medicare decision in order to file a claim with the secondary insurance next we have option 2 this option allows the beneficiary to receive the non-covered items or services and pay for them out-of-pocket with option two no claim will be filed and Medicare will not be billed there are no appeal rights associated with this option because no claim has been filed and lastly we have option three with option three the beneficiary does not want the care or item in question if the beneficiary checks this box that means they understand that no additional care or items will be provided in consequently there are no appeal rights associated with this option a beneficiary or their representative must choose only one of these three options under no circumstances can you decide for the beneficiary which of the three options to select if you pre select an option the notice is invalid however if at the beneficiary's request you may enter the beneficiary selection if they are physically unable to do so in this case you must make a note on the ABN accordingly if there are multiple items or services listed in blank D in the beneficiary wants to receive some but not all of the items or services you can comply with this request by using more than one ABN you can furnish an additional ABN listing the items or services the beneficiary wishes to receive with the corresponding option if the beneficiary cannot or will not make a choice you should make a note of that on the ABN for example beneficiary refused to choose an option let's talk about blank H blank H is available for any additional information you may use this space to provide any additional clarification that you believe will be of use to the beneficiary you may use this space to include a statement advising the beneficiary to notify their doctor that they did not receive the tests that were ordered or an additional dated witness signature or any other necessary notations that will clarify the ABN for the beneficiary notations in blank H will be assumed to have been made on the same day the date in blank J if notations are made on different dates those dates should be included in blank h next we have blank I the signature box once the beneficiary reviews and understands the information contained in the ABN the signature box is to be signed by the beneficiary or their representative you cannot have the beneficiary sign a blank ABN the beneficiary or their representative signature on the ABN indicates that they have received the notice and understand its contents if a representative signs on behalf of a beneficiary he or she should write out representative in parentheses after their signature the representatives name should be clearly legible or noted in print lastly we have blank J the date the beneficiary or their representative must write the date they signed the ABN if the beneficiary has physical difficulty with writing and requests assistance in completing this blank you may insert the date for them stay tuned to 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