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- Effective Date Set for Revised ABN Form
May 24, 2023
The revised Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is now available to download from the Centers for Medicare & Medicaid Services (CMS). Affected organizations must start using the updated ABN form by June 30, 2023.
The form is issued by various providers, physicians, practitioners, and suppliers to Medicare fee-for-service beneficiaries when Medicare payment for care and services is expected to be denied. The ABN transfers potential financial liability to the Medicare beneficiary and must be completed by organizations and beneficiaries.
Revisions to the form do not affect what organizations must document on the form or signature requirements from beneficiaries.
Affected ACHC Programs
Accreditation Commission for Health Care (ACHC) programs impacted by the update include DMEPOS, Home Health, Home Infusion Therapy, Hospice, and Palliative Care accreditation.
Information provided below details situations that do or do not require an organization to issue an ABN form:
ABN Required
- When DMEPOS items are not reasonable or medically necessary but the patient chooses to receive them.
- The supplier does not have documentation that the beneficiary qualifies for coverage of the DMEPOS item. For example, the beneficiary does not have the required diagnosis or test results to qualify, or when a denial of Advanced Determination of Medical Coverage (ADMC) has been received.
- It is known that the beneficiary received the same or similar item in the past five years, and it is reasonable that the claim will be denied.
- The beneficiary is using a quantity of products beyond what Medicare allows. For example, the beneficiary wants more catheters per month than Medicare will allow.
- The beneficiary chooses a DMEPOS item that is an upgrade to an item CMS will cover. For example, the beneficiary wants to have a full electric hospital bed instead of a semi-electric hospital bed that will be covered.
- When a supplier provides a competitively bid DMEPOS item to a beneficiary in a bid area and the supplier was not a bid/contract winner.
ABN Not Required
- The beneficiary is covered under a Medicare Advantage program.
- The DMEPOS item provided is statutorily excluded from coverage, such as:
- DMEPOS items specifically designed to be used outside of the home.
- DMEPOS equipment and related accessories provided to beneficiaries in nursing facilities.
- Orthopedic shoes or inserts not attached to a leg brace or covered under therapeutic shoes for diabetic benefit.
- Personal comfort or convenience items such as grab bars and other bathroom safety equipment.
- The DMEPOS item does not meet the definition of a Medicare benefit, such as:
- Enteral nutrients administered orally.
- Surgical dressings used to cleanse a wound or clean intact skin.
- Nondurable items not covered under any other benefit, like compression stockings.
ABN Required
- Prior to providing home health services that are not reasonable and medically necessary but the Medicare beneficiary chooses to receive the care.
- Services provided are custodial care only.
- The beneficiary does not meet Medicare home health benefit requirements. For example, the beneficiary is not homebound or does not require intermittent skilled services.
- There is a reduction of services, such as the frequency or number of visits by a discipline, or termination of services — but the beneficiary wants to continue receiving the care.
ABN Not Required
- When the home health agency performs an initial assessment, prior to admission, and does not admit the beneficiary.
- When the services provided are never covered by the home health Medicare benefit.
- When telehealth monitoring is used as an adjunct to the covered home health care.
- For non-covered items/services that are part of care covered in total under a Medicare bundled payment (e.g., home health prospective payment system episode payment).
ABN Required
- Prior to providing an item or service that is usually paid for by Medicare under Part B but may not be paid for in this situation because it is not considered medically reasonable and necessary.
- There is a reduction of services, such as the frequency or number of visits by a discipline, or termination of services — but the beneficiary wants to continue receiving the care.
ABN Not Required
- When the home infusion therapy supplier performs an initial assessment, prior to admission, and does not admit the beneficiary.
- When the services provided are never covered by the Medicare Part B benefit.
Mandatory use of the ABN is limited for hospices. Hospice providers are responsible for providing the form to Medicare beneficiaries in accordance with guidelines listed below for items and services billable to the hospice. Hospices are not responsible for issuing an ABN when a hospice patient seeks care or services outside of the hospice’s jurisdiction.
ABN Required
- The beneficiary is determined to be ineligible because they are no longer considered to be “terminally ill,” as defined in §1879(g)(2) of the Act, and want to continue receiving hospice services.
- Specific items or services that are billed separately from the hospice payment, such as physician services, are not reasonable and necessary, as defined in either §1862(a)(1)(A) or §1862(a)(1)(C).
- The level of hospice care is determined to be not reasonable or medically necessary, as defined in §1862(a)(1)(A) or §1862(a)(1)(C), specifically for the management of the terminal illness and/or related conditions.
- The beneficiary chooses to receive inpatient hospice care in a hospital that is not under contract with the hospice. The hospice may delegate delivery of the ABN to the hospital in these cases.
ABN Not Required
- When the beneficiary or their legal representative revokes the hospice Medicare benefit.
- When the beneficiary or their legal representative requests a transfer to another hospice.
- When respite care exceeds five consecutive days. When respite care exceeds five consecutive days, an ABN is not required because additional days of respite care are not part of the hospice Medicare benefit. Hospice providers can issue the ABN as an optional notice to inform the beneficiary or their legal representative of their financial liability when more than five days of respite care will be provided.
- When the hospice fails to conduct the required face-to-face encounter with the beneficiary. The ABN must not be issued when the face-to-face requirement for hospice recertification is not met within the required time frame. Failure to meet the face-to-face encounter requirement for recertification should not be misrepresented as a determination that the beneficiary is no longer terminally ill.
- When a beneficiary resides in a nursing facility. Since room and board are not part of the hospice Medicare benefit, an ABN would not be required when the beneficiary elects the hospice Medicare benefit and continues to pay out of pocket for long-term care room and board.
ABN Required
- Prior to providing an item or service that is usually paid for by Medicare under Part B but may not be paid for in this situation because it is not considered medically reasonable and necessary.
- There is a reduction of services, such as the frequency or number of visits by a discipline, or termination of services — but the beneficiary wants to continue receiving the care.
ABN Not Required
- When the palliative care provider performs an initial assessment, prior to admission, and does not admit the patient.
- When the services provided are never covered by the Medicare Part B benefit.
CMS Guidance
Additional guidance on issuing the ABN can be found in Section 50, Chapter 30, of the Medicare Claims Processing Manual.
The form is still available in English and Spanish, including large print versions in both languages. Organizations can start using the revised form before June 30.
CMS also provides instructions on how to complete the ABN form.
Here for You
ACHC is more than an accreditor. We are your partner. For more information, contact your Account Advisor, email [email protected], or call (855) 937-2242.
Accreditation Commission for Health Care, Inc.