Advance beneficiary notice of noncoverage may be required for what patient?

For services under the Home Health Prospective Payment System (HH PPS) the Advance Beneficiary Notice (ABN) (CMS-R-131) is designed to protect the beneficiary and the home health agency (HHA). It informs the beneficiary of an expectation that Medicare will not pay for the care, and allows them to make an informed decision about whether to continue care. An ABN must be given to the beneficiary when the care is physician-ordered and a Medicare denial is expected for one of the following statutory reasons:

• Services not medically reasonable and necessary (under § 1862(a)(1) of the Act);
• Services are for custodial care only (under § 1862(a)(9) of the Act);
• Beneficiary is not homebound (under § 1879(g)(1)(A) of the Act);
• Beneficiary does not meet intermittent care requirements (under § 1879(g)(1)(B) of the Act).

There are three triggering events for which an ABN must be given:

• Initiation of Services, when you determine at the start of care, that an item and/or services may not be covered by Medicare.
• Reduction of Services, to inform the beneficiary of cessation of one discipline when another is continuing, or an unplanned decrease in number of visits provided.
• Termination of Services, when the HHA determines the services may no longer be covered and the beneficiary asks to continue services.

An ABN cannot be used to transfer liability to the beneficiary when there is a concern that a billing requirement may not be met. (For example, an ABN cannot be issued at initiation of home care services if the provider face-to-face encounter requirement is not met.)

ABN requirements also apply to a beneficiary who is eligible for both Original Medicare and Medicaid (dually eligible) or is covered by Original Medicare and another insurance program or payer. For additional information about the use of ABNs for dually eligible beneficiaries, refer to the Medicare Claims Processing Manual, Pub. 100-04, Ch. 30, §50.15.4.C.

ABN For Outpatient Therapy Services

Section 603 (c) of the American Taxpayer Relief Act (ATRA) amended § 1833 (g)(5) of the Act to provide protection to beneficiaries receiving outpatient therapy services (home health type of bill 34X) on or after January 1, 2013, when services are denied and are in excess of therapy cap amounts and don't qualify for a therapy cap exception.

If a beneficiary will be receiving noncovered therapy services because the services are not medically necessary and reasonable, an ABN must be issued before the services are provided so that the beneficiary can choose whether to get the services and accept financial responsibility for them.

When the goals of the plan of care (POC) have been met, but the patient wants continued therapy, the ABN is required, regardless of whether the therapy services exceed the cap amount. If the goals in the POC have not been met, and continued therapy is medically reasonable and necessary, the ABN is not required.

A home health agency can be held liable if the ABN is determined to be invalid. Refer to the Invalid ABNs and HHCCNs web page for scenarios of when an ABN would be considered invalid.

An ABN, Form CMS-R-131, is a standardized notice that a health care provider/supplier must give to a Medicare beneficiary, before providing certain Medicare Part B or Part A items or services.

Access the below information from this page.

Overview

The ABN must be issued to a beneficiary with enough time prior to the service/procedure for the beneficiary to make an informed decision about whether, or not, to have the procedure/service. It must be issued when the health care provider (including independent laboratories, physicians, practitioners and suppliers) believes that Medicare may not pay for an item or service because of medical necessity, frequency limitations, discontinued services, experimental and investigational, and not safe or proven effective.

By providing the ABN in advance of the procedure/service, it gives a beneficiary the opportunity to decide whether to receive the service and accept financial responsibility if denied by Medicare. It also serves as proof that the beneficiary was advised of potential financial responsibility. If the provider does not deliver a valid ABN to the beneficiary, the beneficiary cannot be billed.

CMS strongly encourages healthcare providers and suppliers to issue an ABN for care that is never covered. However, an ABN is not required for care that is either statutorily excluded from coverage under Medicare (care that is never covered) or most care that fails to meet a technical benefit requirement (lacks required certification). An ABN must not be used for all services and is not required for services that are statutorily excluded. Such as: vitamins, nutritional counseling, x-rays, office visit, and therapy.

Once an ABN is issued, it is no longer required to be issued annually. An ABN remains effective as long as there is no change in: care from what is described on the original ABN, beneficiary’s health status or Medicare coverage guidelines.

If there are ANY changes, a new ABN is required.

Medical Necessity

Medical Necessity is defined as services that are reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member and are not excluded under another provision of the Medicare Program.

Coverage of certain items/services is limited by the diagnosis. If the diagnosis listed on the claim is deemed not medically necessary, the procedure is denied. Limited coverage may be the result of National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs). The CMS Medicare Coverage Database (MCD) contains all NCDs and LCDs, local policy articles and proposed NCD decisions. View the CMS . The official versions of LCDs may be viewed by contractor, state or alphabetically.

42 C.F.R.411.406 states that a healthcare provider or supplier that furnished services which constitute custodial care under 411.15(g) or that are not reasonable and necessary under 411.15(k) is considered to have known that the services were not covered if any one of the conditions listed below are met:

1. Notice from the Quality Improvement Organization (QIO), intermediary or carrier. The QIO, intermediary or carrier had informed the provider, practitioner or supplier that the services furnished were not covered or that similar or reasonably comparable services were not covered.
2. Notice from the utilization review committee or the beneficiary's attending physician. The utilization review group or committee for the provider or the beneficiary's attending physician had informed the provider that these services were not covered.
3. Notice from the provider, practitioner or supplier to the beneficiary. Before the services were furnished, the provider, practitioner or supplier informed the beneficiary that
   1. The services were not covered; or
   2. The beneficiary no longer needed covered services.
4. Knowledge based on experience, actual notice or constructive notice. It is clear that the healthcare provider or supplier could have been expected to have known that the services were excluded from coverage on the basis of the following:
   1. Its receipt of CMS notices, including manual issuances, bulletins, or other written guides or directives from intermediaries, carriers or QIOs including notification of QIO screening criteria specific to the condition of the beneficiary for whom the furnished services are at issue and of medical procedures subject to preadmission review by the QIO.
   2. Federal Register publications containing notice of national coverage decisions or of other specifications regarding non-coverage of an item or service.
   3. Its knowledge of what are considered acceptable standards of practice by the local medical community.

ABN Triggering Events

An ABN is required when an item or service is expected to be denied. This may occur at any one of three points during a course of treatment which are initiation, reduction and termination, also known as "triggering events."

When would you use an ABN?

What does ABN stand for in medical terms?