Appeal on denial of ABN

Advance Beneficiary Notice (ABN) Reminder (GEN)

The Appeals Department has seen multiple invalid Advance Beneficiary Notice (ABN) forms submitted with Redetermination requests and therefore would like to issue the following reminder from the Medicare Claims Processing Manual, Publication 100-04 Chapter 30, Section 40.3.8

“Statements of reasons for predicting Medicare denial of payment at a level of detail similar to the approved “Medical Necessity” messages for MSNs are acceptable for ABN purposes. Simply stating “medically unnecessary” or the equivalent is not an acceptable reason, insofar as it does not at all explain why the physician or supplier believes the items or services will be denied as not reasonable and necessary. To be acceptable, the ABN must give the beneficiary a reasonable idea of why the notifier is predicting the likelihood of Medicare denial so that the beneficiary can make an informed consumer decision whether or not to receive the service and pay for it personally. Listing several reasons which apply in different situations without indicating which reason is applicable in the beneficiary’s particular situation generally is not an acceptable practice, and such an ABN may be defective and may not protect the notifier from liability. However, if more than one reason for denial could apply (e.g., exceeding a frequency limit and “same day” duplication; cases where the reason for denial could depend upon the result of a test; etc.), the contractor will not invalidate an ABN on the basis of citing more than one reason for denial.”

Posted in: appeal instructions,denial basic