Attachment A

Advance Beneficiary Notice (ABN)

Dear Patient:
Patient Name Date of Birth Medicare # Physician
Your physician may order a test/service to be performed which he/she believes to be relevant to evaluate, monitor, and protect your health. However, Medicare will only pay for services which are determined to be “reasonable and necessary.” If Medicare determines that a particular test or service is ‘not reasonable and necessary’ under Medicare standards, then Medicare will deny payment for that test or service. I believe that, in your case, Medicare will deny payment for the test(s)/service(s) listed below for the following reasons:
Procedure / CPT/HCPCSCode / Reason Code
Reason Codes:
  1. Medicare does not pay for tests/services which are for “investigative or research use only.”
  1. Medicare may not pay for these test(s)/service(s) for persons with your diagnosis or no diagnosis.
  1. Medicare allows payment for this test(s)/service(s) a limited number of times within a specified time period. Our institution has no way to know of previous Medicare billings for the same procedure by other institutions.
  1. Medicare does not pay for laboratory test(s)/service(s) which have not been approved by the Food and Drug Administration.
  2. The diagnosis provided does not meet medical necessity requirements.

Beneficiary Agreement to Pay
The effect of signing this ‘Agreement to Pay’ is that you will receive the item or service,
and you will be personally responsible for payment to your physician or healthcare provider.
I have been notified by my physician or healthcare provider that he/she believes, in my case, Medicare will deny payment for the services identified above for the reason stated. I understand that I have the right to decide whether or not to receive the test(s)/service(s) identified above. I have decided to receive the test(s)/service(s). I agree to be personally and fully responsible for payment.
Patient Signature Date Witness Signature Date
Initial here if you want us to bill Medicare for services excluded ______
from coverage and obtain a denial statement. ______Witness 2 Signature Date
Beneficiary Refusal to Receive Service at Own Expense
The effect of signing this ‘Refusal’ is that you will not receive the test or service(s).
I have been notified by my healthcare provider that he/she believes, in my case, Medicare will deny payment for the test or service identified above for the reasons stated. I understand that I have the right to decide whether or not to receive the test or service identified above. I have decided not to receive the service, since I am not willing to be personally responsible for payment.
Patient Signature Date Witness Signature Date
Caution: Medicare Beneficiary - DO NOT SIGN BLANK ABN FORMS
  1. Do not sign the Agreement to Pay on this ABN unless the notice above:
a) specifies the test or service that will be denied, and b) specifies the reason why it will be denied.
  1. Sign and date either the ‘Beneficiary Agreement to Pay’ or the ‘Beneficiary Refusal to Receive Service at Own Expense’. If you refuse to sign either one and you still demand and receive services, you will be personally and fully responsible for payment.
  1. By “personally and fully responsible for payment” we mean that you will have to either pay out of pocket or by any other insurance coverage that you may have.
Your healthcare provider should give you a copy of this completed ABN form. Initial here ______to show your receipt of a copy of this ABN. (Patient initials)

ORIGINAL COPY - Business Office PART 2 - Physician or Registration Office PART 3 - Patient copy