Medicare provides insurance coverage to over 60 million Americans, regardless of their income, medical history, or health status. Medicare coverage is key to providing a plethora of health services, including primary care visits, hospitalizations, prescription medications, preventative services, home health care, and hospice.
However, sometimes practitioners must provide necessary health services that are not covered by Medicare. Many Medicare beneficiaries are over the age of 65 and rely heavily on Medicare to cover their healthcare, meaning unexpected, out-of-pocket costs can put financial stress on beneficiaries. An Advanced Beneficiary Notice form can be leveraged when providing services that are not covered by Medicare.
Read on for our best practices for filling out an ABN form to provide for your Medicare patients.
What is an Advanced Beneficiary Notice Form?
An Advanced Beneficiary Notice form, or ABN form, is a form given to the beneficiary in any case where Medicare is not likely to provide coverage. ABN forms are not required for services that Medicare never covers, only the services they are not likely to cover. An Advanced Beneficiary Notice of noncoverage form transfers the financial liability to the beneficiary and details the items or services that are at risk for not being covered. The ABN form must be completed and delivered before any services are provided.
When attempting to receive coverage for services from Medicare, if the diagnosis on your claim differs from the diagnoses that are covered, you will not receive reimbursement. Claims may also be denied if the service is not deemed medically necessary, experimental, not safe or effective, or exceeds the norm of services provided.
As a healthcare provider, you are considered the “notifier” who is responsible for filling out the ABN form and giving it to the patient. Aside from healthcare providers, notifiers can also include hospice providers, religious non-medical healthcare institutions, and home health agencies.
Tip: Healthie’s internal library of forms includes an electronic version of an ABN form, which can be shared with Medicare patients prior to services.
Filling out the Medicare ABN Form
The header of the ABN form includes the Notifier, Patient Name, and Identification Number. You, as the provider, are the notifier and must include your name, address, and telephone number. You can optionally fill out an identification number for the patient, to link the notice with a related claim. This number may be a medical record number created by the provider, but should not be Medicare numbers, Medicare beneficiary identifiers, or Social Security Numbers. An identification number is not required and will not invalidate the form if left off.
The first section of the body of the form should detail the services provided to the patient. These may be listed as one of the following categories: item, service, lab, test, procedure, care, or equipment. You should provide a general description of the service. You’ll then detail why you believe the services won’t be covered in beneficiary-friendly language. There must be one reason per service listed.
The estimated price of services must also be listed in the body of the form. If multiple services that are typically bundled are listed on the form, you may list one overall price.
The next section allows the beneficiary to select their payment option:
- You, as the provider, will submit a claim to Medicare for payment and if denied, the decision may be appealed
- You will not submit a claim to Medicare, and request payment from the beneficiary at the time of service
- No services will be provided to the beneficiary
✔ Signature Box
Once the beneficiary has reviewed the information in the ABN form, they must sign and date it to indicate that they have received the notice and understand its contents.
✔ Modifier Codes for Insurance Claims
When submitting a claim for Medicare services that are not covered, you must include one of the following codes to indicate the status of the ABN:
- GA Modifier: This code indicates that an ABN form is on file, and the provider may bill the patient for services provided.
- GX Modifier: Attach this code if an ABN form was issued for services that are not covered by Medicare.
- GY Modifier: You can use this code to indicate that you know the services provided will not be covered by Medicare.
- GZ Modifier: Use this code when an ABN form was not provided, but may have been necessary.
How to Leverage Healthie for Intake Paperwork and Forms
Healthie’s intake form system makes it easy to automatically and electronically collect health information, e-signatures, payment details (credit cards and insurance), and other forms needed for care.
- Leverage Healthie’s internal library and specialty forms (including an ABN form, COVID-19 Screening form, assessment forms, and more)
- Allow clients to electronically fill out their forms within the Healthie portal
- Upload existing forms that you already use in your business
- Build your own custom forms or leverage Healthie’s library of forms
- Receive notifications as clients complete their forms
- Send reminders to clients to complete forms
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