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Advance Beneficiary Notice of Noncoverage—Option 2 National Government Services, the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) has been asked to provide guidance on what suppliers should do if the beneficiary selects option 2 on the Advance Beneficiary Notice of Noncoverage (ABN) (i.e., CMS-R-131 Form), but then later changes his/her mind. Option 2 on the ABN states: I want the item/service listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. Suppliers have requested responses to the following questions. Question: Are suppliers obligated to submit a claim to Medicare? Answer: The mandatory claim submission rules outlined in Section 1848 of the Social Security Act require that all suppliers must complete and submit both assigned and non-assigned DMEPOS claims for beneficiaries. Beneficiaries should not be asked to file their own claims. However, suppliers are not required to file claims on behalf of Medicare beneficiaries for items or services statutorily excluded from coverage (i.e., Medicare never covers the item/service). However, if the beneficiary (or his/her representative) believes that the item/service could potentially be be covered by Medicare or desires a formal Medicare determination, the supplier must file a claim for that service to effectuate the beneficiary's right to a determination. Question: How long does the patient have to change their mind? Answer: One year is the limit for use of a single ABN for an extended course of treatment; if the course of treatment extends beyond one year, a new ABN is required for the remainder of the course of treatment. Therefore, the patient would have up to one year to change his/her option selection on the ABN. Question: If the patient changes his/her mind, how should the supplier document this change? Answer: The supplier should annotate the change to the original ABN and have the patient re-sign and date the ABN. Suppliers are also reminded that if they plan on submitting an assigned claim to Medicare that any payment previously collected from the patient excluding twenty percent of the approved charge (coinsurance), unpaid deductible, or non-covered charge amounts must be refunded to the patient. Suppliers who do not accept assignment may continue to request payment in full at the time that the service is provided if the claim for this service is unassigned. Additional information regarding the completion of the ABN can be found in Chapter 10 of the Jurisdiction B DME MAC Supplier Manual at: http://www.ngsmedicare.com/NGSMedicare/DMEMAC/EducationandSupport/ToolsandMaterials/SupManual/chapter10.aspx You can access the ABN CMS-R-131 Form http://www.cms.hhs.gov/BNI/02_ABN.asp#TopOfPage on the CMS Web site. |
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